Accidental insertion of a percutaneous venovenous cannula into the persistent left superior vena cava of a patient undergoing liver transplantation

Persistent Left Superior Vena Cava—When a Left-Sided Central Line Does Not Make the Turn: A Case Report

A 59-year-old male presenting for a living nonrelated kidney transplant has an intraoperative left internal jugular central venous catheter placed for operative access and monitoring. Post-anesthesia care unit postoperative chest X-ray shows possible aortic placement as read by radiology. The catheter is confirmed venous on insertion, with monitoring during the operation, and with repeat transduction and venous blood gas results postoperatively. A follow-up computed tomography scan shows findings consistent with persistent left superior vena cava. This can be associated with other cardiac abnormalities and an increased risk of complications, both mechanical and physiological. Care should be taken in patients identified with persistent left superior vena cava to prevent complications in future procedures.

Unusual venous route of pulmonary artery catheter in a liver transplant recipient: pericardiophrenic or highest intercostal vein?: a case report

We report an extraordinary case in which the venous route for pulmonary artery catheterization was unusual. A 41 year-old woman with an end-stage liver disease underwent a living-donor liver transplantation. After induction of anesthesia, the pulmonary artery catheter was revealed to be advanced into the left brachiocephalic vein and then slipped into another vein that drains into the left brachiocephalic vein. In this case, we assumed that the catheter had most likely slipped into the left pericardiophrenic vein since the catheter follows the left heart border similarly to the route of this vein according to the chest X-ray. Patients with liver cirrhosis develop many collateral vessels and have enlarged veins due to portal hypertension, which makes this vascular route possible. We present this case for anesthesiologists to be aware of the possibilities of unusual venous route due to dilated collateral vessels especially in liver transplant patients.

Complications related to invasive hemodynamic monitors during adult liver transplantation

The rate of complications directly related to invasive monitors during liver transplantation (LT) was reviewed in 1206 consecutive adult LTs performed over 8.6 yr (1/1/2004-7/31/2012). The designated anesthesiologists placed intra-operative monitors, including two arterial catheters (via the radial and the right femoral arteries), central venous catheters (a 9 Fr. catheter and an 18 Fr. veno-venous bypass [VVB] return cannula in an internal jugular vein), a pulmonary artery catheter, and a transesophageal echocardiography (TEE) probe. A 17 Fr. VVB drainage cannula was placed via the left femoral vein. No Clavien-Dindo Grade V (death) or Grade IV (organ dysfunction) complication was identified. Nine Grade III complications (requiring surgical intervention) and 15 Grade II complications (conservative treatment) were noted. Seven (0.58% in 1206 cases) were related to a femoral arterial line with Grade III of four; seven (0.58%) were due to VVB return cannula in the femoral vein with Grade III of one; four (0.33%) were related to central venous catheters with Grade III of two; four (0.33%) were due to a TEE probe with Grade III of two; and two minor complications (0.17%) that were related to a radial arterial line. No complication was observed with a pulmonary arterial catheter. Current invasive monitors placed during LT have an acceptable risk.