Enlarged jugular veins

An 83-year-old woman presented to our emergency department with a two-week history of progressive dyspnoea on exertion and leg oedema, and no syncope. She had a history of hypertension, diabetes mellitus type 2, renal insufficiency, and left bundle branch block. She was clinically mildly decompensated. The ECG showed sinus rhythm with total AV block and a ventricular escape rhythm of 30/min. Echocardiography showed normal left and right ventricular systolic function and a dilated inferior vena cava with decreased variation. During pacemaker implantation, a remarkable anatomy of the jugular veins was noticed. An aberrant trajectory of the wire was perceived from the left subclavian vein to the contralateral side (Fig. 1a and online video). After contrast injection, two large veins were observed running parallel to one another which were connected caudally (Fig. 1b). Furthermore, the left brachiocephalic vein and superior vena cava (Fig. 1b and 1c) are appreciated. We concluded that the anatomy consisted of enlarged anterior jugular veins (venae jugulares anteriores) and a jugular arch (arcus venosus juguli) [1]. This is a common anatomy, but these jugular veins are rarely enlarged [2].