A 53-year-old male patient presented with chest pain and tightness for one hour. Frontal chest radiograph showed a tortuous aorta and a subtle aortic nipple at the left aspect of the aortic arch; the azygos vein shadow was not seen. Contrast-enhanced multi-detector row computed tomography (MDCT) showed absent azygos vein and prominent left superior intercostal vein communicating the accessory hemiazygos vein to the left brachiocephalic vein. Clinical improvement was noted. The patient was then discharged from the emergency department.
