A 68-year-old woman underwent ultrasonography for determination of the spatial relationship between her right common carotid artery (CA) and right internal jugular vein for guidance in inserting the central venous catheter before surgery. The image showed that the brachiocephalic artery (BA) deviated to the midline from the cephalic side of the right clavicle (Fig. 1A). The BA coiled in front of the thyroid gland at the level of the 6th cervical vertebra (Fig. 1B), and diverged into the right common CA and right subclavian artery at the normal CA position.

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Fig. 1. (A) The right side of the figure corresponds to the right side of the body. (B) The part of the BA near the trachea was the peripheral side (Video 1: the video is a scan of the front of the median neck using color and non-color Doppler imaging).
a: right clavicle; b: brachiocephalic artery (BA); c: common carotid artery; d: subclavian artery; e: internal jugular vein (IJV); f: trachea (T); g: thyroid gland.

Various anatomical variations of the BA have been described before. These include abnormal length, variations in position of the bifurcation point, atypical configurations, and variable size; but it is difficult to identify the frequency of each occurrence. A few previous reports showed that the carotid sheath unites with the visceral fascia at the level of the thyroid gland.^1-3 During anesthesia, abnormal bifurcation and running direction of BA are rarely identified by pre-scanning ultrasonography prior to central venous catheterization. Therefore, the procedure to confirm the perivascular structures and spatial positions of both the common CA and the internal jugular vein is very important to avoid inadvertent puncture, catastrophic hemorrhage, and other complications.

Conflicts of Interest

Author declares no conflicts of interest.

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