Unexpected course of central venous catheter; persistent left superior vena cava

CASE

A 25-year-old male with a history of end-stage renal disease on hemodialysis (HD) was admitted for methicillin-sensitive staphylococcus aureus bacteremia. Appropriate antibiotics were started, and his HD catheter was replaced with a temporary one in the left internal jugular vein (LIJ). A follow-up chest X-ray revealed an unusual course of the catheter and persistent left superior vena cava (PLSVC) was suspected (Fig. 1A). A follow-up cardiac computed tomography (CT) confirmed the presence of PLSVC containing HD catheter that drains into coronary sinus (CS). It also showed right-sided SVC and inferior vena cava drain appropriately into the right atrium (RA) (Fig. 1B, C). The LIJ HD catheter was replaced with a right internal jugular vein one. Transthoracic and transesophageal echocardiogram revealed dilated CS (Figs 1D, 2).

Figure 1.

Panel A: Chest X-ray showing the course of the HD catheter in the LIJ vein down an apparent left SVC. Panel B: Cardiac CT showing the right SVC (blue asterisk), persistent left SVC (yellow asterisk) with the HD catheter within its lumen and its tip in the CS. Panel C: Cardiac CT showing the HD catheter in the left SVC (yellow asterisk) in dilated CS draining into the RA. Panel D: Transthoracic echocardiography, parasternal long axis view illustrating dilated CS. AA: ascending aorta, CS: coronary sinus, DA: descending aorta, LA: left atrium, LV: left ventricle, RA: right atrium, PA: pulmonary artery, RPA: right pulmonary artery, LPA: left pulmonary artery.

Figure 2.

Panels A, B: Transesophageal echocardiogram (TEE), mid esophageal view illustrating a dilated CS (asterisk). Panel C: TTE with color Doppler showing the direction of the flow within the CS. LA: left atrium, LV: left ventricle.

PLSCV is the most common thoracic venous return congenital anomaly with an incidence of 0.3–0.5% in normal hearts and up to 4.5% with congenital heart disease [1]. In most cases, it coexists with right SVC, and it drains into RA with no hemodynamic significance. However, in 10–20% it drains into the left atrium causing a right to left shunt [2]. It usually gets detected on a routine chest imaging, during central venous catheterization or invasive cardiac procedures. And the diagnosis can be confirmed through echocardiography contrast study by injecting agitated saline into the left arm vein [2]. Dilated CS should raise suspicion of PLSVC as it is the most common cause of dilated CS through enhancing venous return. However, other causes of dilated CS should be evaluated, which include total anomalous anomalous pulmonary venous return, CS thrombosis, a coronary arterio-venous fistula or increased RA pressures [3]. PLSVC can have various clinical implications as it can pose a challenge when accessing the left subclavian vein for central venous access, during catheter placement or invasive cardiac procedures. CS thrombosis is a rare but serious complications associated with PLSVC instrumentation [2].

CONFLICT OF INTEREST DISCLOSURE

None.

FUNDING DISCLOSURE

None.