The azygos vein is a major vein located along the right side of the thoracic vertebral column. It originates from the union of the right lumbar vein and the right subcostal vein or as a continuation of the inferior vena cava. It ascends through the posterior mediastinum, running upward along the right side of the vertebrae, behind the esophagus and in front of the thoracic aorta. The azygos vein receives blood from the posterior intercostal veins, hemiazygos vein, and accessory hemiazygos vein. It arches over the root of the right lung before draining into the superior vena cava, which carries blood back to the heart.
Anatomy
Origin
The azygos vein typically arises from the right ascending lumbar vein and the right subcostal vein at the level of the first or second lumbar vertebra. In some cases, it can originate as a direct continuation of the inferior vena cava. The exact point of origin can vary, but it is usually found in the lower part of the thorax or upper abdomen. The vein begins in the posterior abdominal wall and ascends toward the thorax through the aortic hiatus of the diaphragm, entering the thoracic cavity.
Course
The azygos vein ascends vertically along the right side of the thoracic vertebral column. It runs in the posterior mediastinum, a region located between the lungs, behind the heart and in front of the thoracic vertebrae. As the vein ascends, it lies posterior to the esophagus and to the right of the thoracic duct. The azygos vein runs along the right side of the vertebral bodies, closely associated with the thoracic vertebrae, and receives tributaries from various veins as it ascends.
At around the level of the T4 vertebra, the azygos vein curves forward, forming the azygos arch. This arch passes over the root of the right lung and empties into the superior vena cava, which then carries the blood back to the heart. The vein travels in the mediastinum between the azygos arch and the right lung before making this connection.
Tributaries
The azygos vein receives blood from multiple tributaries throughout its course, including:
- Posterior intercostal veins: These veins drain the intercostal spaces between the ribs and contribute to the azygos vein. On the right side, the posterior intercostal veins directly empty into the azygos vein.
- Hemiazygos vein: The hemiazygos vein drains the lower left thoracic wall and passes across the midline to join the azygos vein, usually around the level of the T8 vertebra.
- Accessory hemiazygos vein: This vein drains the upper left thoracic wall and similarly crosses to join the azygos vein, typically around the level of the T7 or T8 vertebra.
- Esophageal veins: Veins from the esophagus drain into the azygos vein, contributing to its flow.
- Mediastinal veins: These small veins drain the mediastinal structures, such as the pericardium and the lymph nodes, into the azygos vein.
- Bronchial veins: Some of the veins that drain the bronchi and lung tissue may also empty into the azygos vein.
- Vertebral veins: Some venous drainage from the vertebral bodies and spinal cord may enter the azygos system via smaller tributaries.
Relations
- Anterior relations: Anterior to the azygos vein is the esophagus, which runs along the same vertical axis but is positioned more anteriorly in the posterior mediastinum. The right lung root is also anterior to the azygos vein, where the vein forms an arch over it as it empties into the superior vena cava.
- Posterior relations: The azygos vein is closely related to the thoracic vertebrae as it runs along the right side of the vertebral column. Posteriorly, it is also related to the vertebral bodies and the sympathetic trunk, which runs parallel to the vertebral column.
- Medial relations: Medially, the azygos vein is related to the thoracic duct (on the left side) and the descending aorta, which lies further to the left.
- Lateral relations: Laterally, the azygos vein is related to the pleura of the right lung and the right bronchus, especially at the level of the azygos arch.
Azygos Arch
The azygos arch is a defining feature of the azygos vein’s anatomy. As the azygos vein reaches the superior portion of the thoracic cavity, it curves anteriorly to pass over the root of the right lung. This arch then empties into the superior vena cava at approximately the level of the fourth thoracic vertebra (T4). The azygos arch is visible in imaging studies like chest X-rays and CT scans, and it serves as a key anatomical landmark.
Termination
The azygos vein terminates by draining into the superior vena cava. After forming the azygos arch, it empties into the superior vena cava just before the superior vena cava enters the right atrium of the heart. This connection is critical for returning deoxygenated blood from the thoracic wall and posterior chest structures back to the heart for reoxygenation.
Variations
The anatomy of the azygos vein can exhibit variations in its origin, course, and tributaries. Some individuals may have an azygos vein that originates directly from the inferior vena cava, while others may have variations in the level at which the hemiazygos or accessory hemiazygos veins join the azygos vein. Additionally, in some individuals, the azygos vein may be smaller or less prominent, depending on the development of collateral venous systems. In rare cases, the azygos vein may even be duplicated.
Communication with Other Venous Systems
The azygos vein communicates with other major venous systems, such as the inferior vena cava, through its connections with the lumbar veins and subcostal veins in the abdomen. It also connects with the internal vertebral venous plexus, which drains the vertebrae and spinal cord, allowing for collateral circulation between the thorax, abdomen, and vertebral structures. These communications make the azygos system an important venous pathway for bypassing obstructions or increased pressure in the vena cava.
Function
Venous Drainage of the Thoracic Wall
The primary function of the azygos vein is to drain venous blood from the posterior thoracic wall. It collects deoxygenated blood from the posterior intercostal veins, which run between the ribs and drain the intercostal muscles, bones, and other structures in the thoracic wall. By transporting this blood toward the heart, the azygos vein ensures proper circulation within the thoracic wall, removing metabolic waste and deoxygenated blood from the muscles and bones involved in respiration and movement of the chest.
Drainage from the Posterior Intercostal Veins
The azygos vein plays a key role in draining the posterior intercostal veins on the right side of the body. The posterior intercostal veins run along each intercostal space and drain blood from the muscles and tissues between the ribs. These veins merge into the azygos vein as it ascends the right side of the vertebral column, collecting venous blood from the thoracic wall. This ensures that the intercostal spaces are efficiently drained of venous blood, which is especially important during physical activity, where the intercostal muscles are heavily involved in respiration.
Venous Return from the Hemiazygos and Accessory Hemiazygos Veins
The azygos vein also functions as the central venous channel for receiving blood from the hemiazygos and accessory hemiazygos veins on the left side of the thorax. The hemiazygos vein drains the lower left posterior thoracic wall, while the accessory hemiazygos vein drains the upper left thoracic wall. These veins cross the midline to join the azygos vein, ensuring that blood from both sides of the thorax is returned to the central circulation. The azygos vein’s ability to collect blood from both the right and left thoracic walls highlights its role as a unifying structure in the thoracic venous system.
Drainage of the Mediastinum
The azygos vein also serves an important function in draining the mediastinum, the central compartment of the thoracic cavity that contains vital structures such as the heart, esophagus, trachea, and major blood vessels. The azygos vein receives venous blood from the esophageal veins, bronchial veins, and mediastinal veins, helping to drain blood from the esophagus, lungs, bronchi, and surrounding tissues. This drainage ensures that the central thoracic structures maintain proper circulation and that deoxygenated blood from these organs is efficiently removed.
Collateral Circulation in Venous Obstruction
One of the most important functions of the azygos vein is to provide a collateral pathway for venous blood flow in cases of venous obstruction or increased pressure in the major veins, such as the inferior vena cava (IVC) or superior vena cava (SVC). Because the azygos vein communicates with both the IVC and the SVC, it can serve as a bypass channel when one of these large veins is blocked or narrowed, ensuring that venous blood from the lower body or thorax can still reach the heart. In this way, the azygos vein helps maintain venous return and systemic circulation, even when the primary venous pathways are compromised.
Communication with the Vertebral Venous Plexus
The azygos vein also plays a role in draining venous blood from the vertebral column. Through its connections with the vertebral venous plexus, which surrounds the spinal cord and vertebrae, the azygos vein helps drain blood from the spine and spinal cord. This is particularly important in conditions where increased pressure in the vertebral venous system needs to be relieved. The vertebral venous plexus is a valveless system, meaning that blood can flow bidirectionally, and the azygos vein serves as an important outlet for this venous drainage.
Drainage from the Esophagus and Bronchi
The azygos vein also contributes to the drainage of the esophagus and bronchi, two key structures within the mediastinum. The esophageal veins and bronchial veins drain into the azygos system, allowing deoxygenated blood from the esophagus and the bronchial tree to be transported toward the heart. This function is crucial for maintaining the health of these vital organs, ensuring that venous blood from the digestive and respiratory systems is efficiently returned to the central circulation.
Support for Venous Return During Respiration
During respiration, the thorax undergoes significant pressure changes as the lungs expand and contract. The azygos vein plays a role in supporting venous return during these respiratory movements. As the diaphragm moves during inhalation and exhalation, pressure within the thoracic and abdominal cavities fluctuates, affecting venous return to the heart. The azygos vein, due to its location in the posterior mediastinum and its connection to the IVC and SVC, helps regulate these pressure changes and facilitates the return of venous blood to the heart, even under changing respiratory pressures.
Regulation of Venous Pressure
The azygos vein helps in the regulation of venous pressure within the thorax and abdomen. Because the azygos system is connected to both the superior and inferior vena cava, it serves as a pressure-balancing system between these two major venous channels. If pressure in the IVC rises (such as during pregnancy, heart failure, or certain types of abdominal surgery), the azygos vein can accommodate the extra blood flow and prevent venous congestion. This regulation of pressure ensures that the venous system remains functional and efficient even under changing conditions.
Drainage from the Thoracic Duct
The thoracic duct, the main lymphatic vessel of the body, runs alongside the azygos vein in the posterior mediastinum. While the thoracic duct primarily drains lymphatic fluid rather than venous blood, the close proximity of these two structures allows for efficient interaction between the venous and lymphatic systems. In some cases, small lymphatic vessels may drain into the azygos system, and the azygos vein serves as a support structure for the thoracic duct, facilitating its function in lymphatic drainage.
Clinical Significance
The azygos vein is clinically significant due to its role in providing an alternative venous pathway when the inferior vena cava (IVC) or superior vena cava (SVC) is obstructed. In cases of SVC syndrome, where the superior vena cava is compressed or blocked (due to tumors, thrombosis, or other causes), the azygos vein serves as a collateral route to return blood from the upper body to the heart. Similarly, in cases of increased pressure in the IVC, the azygos system can help bypass the blockage and maintain venous return.
Additionally, the azygos vein is often involved in conditions such as pulmonary diseases or esophageal varices, where increased pressure in the azygos system can indicate underlying pathology. The azygos vein can also be seen on imaging studies (e.g., chest X-rays, CT scans), and an enlarged azygos vein may indicate cardiovascular or thoracic pathology, including heart failure, cirrhosis, or congenital heart defects.
Its close proximity to the esophagus and vertebral column also makes it a key structure during thoracic surgeries, such as mediastinal procedures, where injury to the azygos vein can lead to significant bleeding.
