Aberrant Left Brachiocephalic Vein versus Persistent Left Superior Vena Cava without Bridging Vein in Adults: Evaluation on Computed Tomography

Case Report: Persistent left superior vena cava: an incidental finding during peripherally inserted central catheter placement

Background

A peripherally inserted central catheter (PICC) is a specialized type of long-term intravenous catheter commonly employed for administering chemotherapy. The operation and management of PICC should exclusively be carried out by trained healthcare professionals equipped with the requisite knowledge of anatomy, procedural technique and patient care. Persistent left superior vena cava (PLSVC) is a vascular malformation which is typically asymptomatic in clinical presentation, almost always identified during invasive surgery or imaging examinations.

Case presentation

Herein, we detailed a case involving a breast cancer patient whose PLSVC was identified during the placement of PICC because of the negative P-wave in electrocardiogram (ECG). Subsequent examination, including chest x-ray imaging, postoperative enhanced CT of the chest, ECG, and consultation with an experienced imaging physician confirmed that the patient's variant type was PLSVC type I. 2160. Removal of the catheter was deemed unnecessary, as the catheter tip was appropriately positioned and no other concomitant cardiovascular malformations were detected.

Conclusion

The PLSVC is a vascular anomaly and is relatively uncommon within the general population. The operator should possess a thorough familiarity with the potential anatomical variations of left superior vena cava, and specialized case profile should be established for patients diagnosed with PLSVC.

Application of Electrocardiogram Localization during Peripherally Inserted Central Catheter Line Insertion into the Persistent Left Superior Vena Cava of Neonates

BACKGROUND

Most neonates with persistent left superior vena cava (PLSVC) have no clinical symptoms or hemodynamic changes, and this anomaly is only found during cardiac catheterization, pacemaker implantation, or central venous catheterization. Electrocardiogram (ECG) localization is helpful for the application of the peripherally inserted central catheter (PICC) technique in neonates with PLSVC.

OBJECTIVE

To explore the characteristic waveforms of the P wave when a PICC under ECG localization is applied in neonates with PLSVC.

STUDY DESIGN

The observation and management strategies for the P wave changes during catheter insertion (CI) of two neonates with PLSVC admitted to our institution between January and July 2020, who underwent PICC line insertion, were summarized.

RESULTS

The characteristic P wave changes in two children with a PICC line inserted via the PLSVC were observed. When a wide inverted P wave appeared on ECG, the catheter was immediately withdrawn by 0.5 cm, a bidirectional P wave gradually appeared and then disappeared. After that, the catheter was further withdrawn by 0.5 cm. After catheterization, the optimal position of the PICC was confirmed by X-ray photography and bedside B-ultrasound. The PICC line was removed as scheduled after indwelling for 18 and 29 days, respectively, in the two cases, and no PICC-related complications occurred during indwelling.

CONCLUSION

The characteristic P wave changes on ECG during CI provide important clinical reference values for the application of the PICC technique under ECG localization in neonates with PLSVC.

KEY POINTS

· Electrocardiogram localization.. · Peripherally inserted central catheter.. · Persistent left superior vena cava..

Analysis of six cancer patients with persistent left superior vena cava identified during central venous access device placement via an intracavitary electrocardiogram

Persistent left superior vena cava (PLSVC) is a rare congenital anomaly. PLSVC can be associated with clinically significant atrial septal defect (ASD) or ventricular septal defect (VSD). It is usually asymptomatic and accidentally detected during invasive procedures or imaging examinations. However, whether central venous access device (CVAD) can be placed and used in patients with PLSVC is controversial. A total of six patients were diagnosed with PLSVC and confirmed by chest CT among 3391 cancer patients who underwent CVAD placement via intracavitary electrocardiogram (IC-EKG) at the Venous Access Center (VAC) from May 2019 to December 2020. The CVADs (peripherally inserted central catheter in four patients and Ports in two patients) of these six patients were left in PLSVC. We analyzed changes in the P-wave in the IC-EKG during CVAD placement and the characteristics of the body surface electrocardiogram in these patients and discussed the catheter tip position in PLSVC. All six patients showed negative P-waves in lead II via IC-EKG from the beginning of catheterization: four patients showed negative P-waves and two showed biphasic P-waves in the body surface electrocardiogram (lead III) before catheterization. CVAD function was normal and no obvious complications were observed during the treatment of these patients. The total retention time of CVADs was 1537 days. For patients with a negative P-wave in lead II via IC-EKG during catheterization, especially in those with a negative or biphasic P-wave in lead III of the body surface electrocardiogram, PLSVC should be considered. CVAD insertion in patients with type I PLSVC is safe under certain conditions, with the proper tip position in the middle to lower part of PLSVC.

Computed tomography and magnetic resonance imaging of congenital thoracic systemic venous anomalies

We present the imaging findings of thoracic systemic venous anomalies diagnosed by computed tomography and magnetic resonance imaging. Persistent left superior vena cava is the commonest anomaly of the thoracic systemic veins encountered either incidentally as an isolated finding or associated with congenital heart disease. Inferior vena cava (IVC) interruption with azygos continuation is the second most common anomaly, which may also be isolated or be associated with left isomerism syndrome. The article will also discuss other rarer systemic venous anomalies including retroaortic brachiocephalic vein and IVC drainage into the left atrium. Finally, the impact of pre-procedure reporting of thoracic systemic venous anomalies on the choice of intervention and patient outcome will be addressed.

Case report of double superior vena cava and double odd vein with hypoplastic left brachiocephalic vein

Persistent left superior vena cava (PLSVC) is a common venous variation that is usually accompanied by an absence of the left brachiocephalic vein, and displays a higher incidence in patients with congenital heart disease. Here, the case of a 57-year-old male patient who was found to have PLSVC on chest computed tomography (CT) during screening for gastric cancer metastasis at the Affiliated Hospital of Qinghai University, is described. Further coronal CT and three-dimensional reconstruction of the chest revealed the patient's double superior vena cava (DSVC), double odd veins, and left brachiocephalic vein dysplasia. The patient did not have congenital heart disease and the case was associated with dysplasia of the left brachiocephalic vein, indicating an unusual and rare venous abnormality. At the time of writing, the patient was receiving antitumour therapy.

Dilated Accessory Hemiazygos Vein Mimicking Aortic Dissection in Setting of Absent Left Brachiocephalic Vein

Although uncommon, aortic dissection can be rapidly fatal with a 20% out-of-hospital mortality which increases at a rate of 1 to 3% every hour [1]. An expeditious diagnosis of acute aortic dissection is therefore imperative. One of the most advantageous diagnostic modalities utilized in the setting of acute aortic dissection is a transesophageal echocardiogram (TEE). In an acute setting, TEE is preferred because of its ability to provide a timely and definitive diagnosis [2]. Despite its diagnostic convenience, clinicians must be aware that there are several entities that may mimic aortic dissection. One of these entities includes a dilated accessory hemiazygos vein. In this report, we present a case of a 66-year-old woman who was found to have a possible Stanford type B dissection in the descending thoracic aorta on a TEE exam in the context of work up prior to an elective electrophysiology study and ablation for paroxysmal atrial fibrillation. CT angiography, however, revealed a dilated accessory hemiazygos vein, a rare congenital vascular anomaly that could potentially mimic aortic dissection leading to misdiagnosis and potentially unnecessary interventions.

Four-Dimensional Echocardiography Is an Accurate Tool for Coronary Sinus Evaluation in Patients with Persistent Left Superior Vena Cava Diagnosis

Persistent left superior vena cava (PLSVC) is a rare vascular congenital anomaly yet the most common for the thoracic venous system. Usually asymptomatic, PLSVC is commonly diagnosed when echocardiography or other cardiovascular imaging is performed. Due to venous drainage abnormality, PLSVC is frequently associated with other anomalies of the intrinsic heart's conduction system, leading to tachy- or brady- arrhythmias. We present the case of a patient with 20 years history of supraventricular rhythm disorders diagnosed with isolated PLSVC. Furthermore, we discuss the diagnostic approach providing insights into four-dimensional echocardiography (4DE) evaluation for PLSVC diagnosis, assuming that there is a direct correlation between coronary sinus dilatation caused by abnormal venous return and supraventricular rhythm disorders. We highlight that correct understanding of the pathophysiology of PLSVC will lead to a reduction in unnecessary and potentially harmful testing, to a shorter diagnostic time and to a financial resource saving, as a whole.

Persistent left superior vena cava: clinical importance and differential diagnoses

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and may be a component of the complex cardiac pathologies. While it is often asymptomatic, it can lead to significant problems such as arrhythmias and cyanosis. Besides, it can cause serious complications during vascular interventional procedures or the surgical treatment of cardiac anomalies (CA). The clinical significance of PLSVC depends on the drainage site and the accompanying CA. In this article, we will describe the epidemiology, embryology, and anatomic variations of PLSVC. Possible accompanying CA and heterotaxy spectrum will be reviewed with the help of multidetector computed tomography (MDCT) images. Radiological pitfalls, differential diagnoses, and the clinical importance of PLSVC will be highlighted.

Persistent left superior vena cava with absent right superior vena cava in adults: CT and clinical findings

PURPOSE

Persistent left superior vena cava (PLSVC) with absent right superior vena cava (ARSVC) is rare. We evaluated CT and clinical findings of adults with ARSVC.

MATERIALS AND METHODS

Our study included 11 adults with ARSVC (mean age, 63 ± 17 years). We evaluated CT findings of the azygos vein system and coronary sinus (CS) using thin slice data of > 64 MDCT. Arrhythmia and congenial heart disease were assessed. We compared the CS diameters between the ARSVC group and the control group of 120 adults with normal vena cava (mean age, 60 ± 4 years).

RESULTS

Adults with ARSVC had no azygos vein arch and the hemiazygos vein continued to PLSVCs via the superior intercostal vein. Eight adults had arrhythmia including conduction disturbance and one arrhythmia was associated with atrial septal defect. All adults with ARSVC had dilated CS larger than 11 mm. The mean diameter of the CS in the ARSVC group was 18.4 mm, and that of the control group was 6.8 mm. CS diameter in the ARSVC group was larger than that in the control group (p < 0.001).

CONCLUSION

Adults with ARSVC had dilated CS and no azygos vein arch. Four adults had conduction disturbance.

The gap between the aorta and the superior vena cava: A sonographic sign of persistent left superior vena cava and associated abnormalities

OBJECTIVES

To assess the distance between the right superior vena cava (SVC) and the aorta in fetuses with bilateral superior vena cava as a possible sonographic marker for this.

METHODS

This was a nested case-control study including 20 cases of bilateral SVC and 40 gestational age-matched controls. The distance between the right SVC and the aorta was measured at the level of the three-vessel trachea view in stored images, as well as the diameters of the aorta and the right SVC.

RESULTS

The distance between the aorta and the right SVC was significantly larger in the cases of a left SVC compared with controls, P < .001. A distance of 2.0 mm or more was found in 70% of the cases and 5% of the controls, with a gestational-age adjusted area under the receiver-operating characteristics (ROC) curve for the diagnosis of left SVC of 0.93 (95% CI 0.87-0.99). The aorta and the right SVC were significantly smaller in cases compared with controls, and there was a significant association with other cardiac and extracardiac abnormalities amongst cases of persistent left SVC.

CONCLUSION

An increased distance between the aorta and the right SVC is associated with the diagnosis of bilateral SVC.