Persistent left superior vena cava: diagnosed by bedside echocardiography in a liver transplant patient: a case report

Case Report of a Left-sided Superior Vena Cava Causing Unique Positioning of Central Line

Introduction

Persistent left-sided superior vena cava is a rare congenital venous malformation. While often clinically asymptomatic, these variations in normal anatomy may give rise to complications with central venous catheter placement.

Case Report

We present a case of a 71-year-old male who presented to the emergency department with sepsis of unknown etiology. A right-sided central venous catheter was placed, and due to a persistent left-sided superior vena cava the post-procedure chest radiograph showed a uniquely positioned catheter tip within the left atrium.

Conclusion

A persistent left-sided superior vena cava may lead to uniquely positioned catheter tip placement on post-procedural imaging. This case demonstrates the need to consider variants in normal venous anatomy, such as persistent left-sided superior vena cava, to aid with correct interpretation of post-procedure imaging findings.

Ultrasound-guided catheterization of the left subclavian vein without recognition of persistent left superior vena cava: A case report

RATIONALE

A persistent left superior vena cava (PLSVC) is rare, but the most common thoracic venous anomaly. We report a case of PLSVC unrecognized during left subclavian vein catheterization using real-time ultrasound-guided supraclavicular approach.

PATIENT CONCERNS

A 79-year-old man with history of hypertension presented with traumatic subdural hemorrhage, subarachnoid hemorrhage, and epidural hemorrhage. Before the operation, a central venous catheter (CVC) was placed into the left subclavian vein.

DIAGNOSES

A dilated coronary sinus on echocardiogram and subsequent agitated saline test confirmed the diagnosis of PLSVC.

INTERVENTIONS

A CVC was placed into the left subclavian vein under real-time ultrasound guide, with supraclavicular approach. A postoperative chest X-ray revealed a left-sided paramediastinal course of the CVC; the CVC was removed under the impression of malposition.

OUTCOMES

The CVC functioned properly.

LESSONS

Ultrasound is used for safe and correct placement of CVC; however, the presence of PLSVC could not be detected by ultrasonography in this case. When the chest radiograph shows the central venous catheter passing along the border of the left heart and a dilated coronary sinus detected on echocardiogram, we should have suspicion of a PLSVC.

Inability to Utilize Retrograde Cardioplegia due to a Persistent Left Superior Vena Cava

A persistent left superior vena cava is a congenital abnormality that affects a minority of the general population. While this finding is not hemodynamically significant in all patients, failure to recognize the altered anatomy in any of these patients can be consequential during procedures such as central venous catheter placement, pacemaker/defibrillator wire placement, and use of retrograde cardioplegia during cardiac surgery. We present a case of an intraoperative diagnosis of a persistent left superior vena cava that altered the original plan to arrest the heart using retrograde cardioplegia. Echocardiography was instrumental in this diagnosis and avoided potentially inadequate myocardial protection during cardiopulmonary bypass.

Left-Sided Persistent Superior Vena Cava with Superior Hemiazygos Arch

Persistent Left-side Superior Vena Cava (PLSVC) is the congenital central venous anomaly draining into the right atrium in 82-90% of cases via coronary sinus produce no haemodynamically significant consequences. In few cases it may drain into the left atrium directly or through the pulmonary veins resulting in right to left shunt. During routine undergraduate dissection, we found a PLSVC formed by the union of left subclavian and left internal jugular veins behind the left sternoclavicular joint was terminated into the right atrium through a larger coronary sinus ostium. Before its termination, PLSVC received a left hemiazygos vein formed by the continuation of the superior and inferior hemiazygos veins. A larger but thin communicating vein was noted between the right superior vena cava and PLSVC. Prior knowledge about such variations is essential in all the intervention procedures on right atrium through the left subclavian approach and also like in our case, the larger coronary sinus ostium if found during transthoracic echocardiography should be considered as an indication for the diagnosis of PLSVC.