1. PATIENT PRESENTATION
A 45‐year‐old female was admitted for encephalopathy after being found unresponsive. The patient was intubated, and a central line was placed in the left internal jugular (IJ) vein. The wire went in smoothly, and all ports flushed and drew back. Confirmatory chest x‐ray (CXR) is shown in Figure 1. Computed tomography (CT) scan confirmed a central line placed in the left IJ with the central line terminating in an anomalous pulmonary vein (Figure 2A,B).
FIGURE 1.
Chest x‐ray showing tip of left internal jugular central venous catheter abnormally located in lateral lung field.
FIGURE 2.
(A and B) Computed tomography (CT) of chest shows the central venous catheter placed in the left superior vena cava with termination in the pulmonary vein due to a likely congenital anomalous pulmonary vein.
2. DIAGNOSIS: PARTIAL ANOMALOUS PULMONARY VENOUS RETURN
Partial anomalous pulmonary venous return (PAPVR) is estimated to affect 0.7% of the population. 1 Note that 80%–90% of cases are on the right side. 2 While generally asymptomatic and found incidentally, some cases of PAPVR cause severe pulmonary hypertension. 1 , 3 CXR and ultrasound can be used to initially detect aberrant placement of a central line. Arterial blood gas showing the PaO2 is higher in the central line than in an arterial sample and is also suggestive of an anomalous pulmonary vein. 1 CT or magnetic resonance imaging should be obtained to definitively diagnose PAPVR. 3 Central lines terminating in an anomalous pulmonary vein should be removed and alternate venous access should be utilized. Long‐term management of PAPVR is dependent on the shunt fraction and right ventricular (RV) function. Close monitoring is sufficient for long‐term management of cases with low shunt fraction and normal RV function. 2 High shunt fraction and RV enlargement are indications for surgical repair to prevent the development of pulmonary hypertension. 2
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Fox L, Yogendran R, LeNoue JR, Bitter CC. Abnormal chest x‐ray after central line. JACEP Open. 2024;5:e13121. 10.1002/emp2.13121
The opinions expressed in this manuscript are the authors, and do not represent the position of the US Air Force, the Department of Defense, or the US Government. This case has not been previously presented.
REFERENCES
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