Abstract
Congenital partial anomalous pulmonary venous return (PAPVR) is rare and present in 0.04%–0.7% of the population. This may pose a significant problem for clinicians performing internal jugular venous catheter placement. This report depicts an abnormal internal jugular venous catheter placement due to a PAPVR to help physicians recognize and deal with variant pulmonary veins.
Keywords: central venous catheter, critical care, partial anomalous pulmonary venous return
INTRODUCTION
Critical patients often require internal jugular venous catheter placement for hemodynamic monitoring and infusion of vasoactive drugs, total parenteral nutrition, and other treatments. If the catheter is placed incorrectly in abnormal areas such as the arterial system, mediastinum, pleura, and other abnormal sites, it may lead to aggravation and even hasten the patient's death. Congenital partial anomalous pulmonary venous return (PAPVR) is rare and present in 0.04%–0.7% of the population. 1 , 2 , 3 This may pose a significant problem for clinicians performing internal jugular venous catheter placement. This report depicts an abnormal internal jugular venous catheter placement due to a PAPVR.
Case
A middle‐aged woman with a primary diagnosis of lymphoma and a coinfection of the lungs required treatment with vasoactive drugs and potassium supplementation. Due to the presence of a lymphoma mass in the neck that interfered with the internal jugular vein puncture, a central venous catheter was placed in the left subclavian vein. However, the blood removed from the catheter was bright red and similar to arterial blood. We performed blood gas analysis on both central venous catheter blood and radial artery blood at the same time. The oxygen partial pressure of the central venous catheter blood was 170 mmHg, while the radial artery blood gas analysis showed an oxygen partial pressure of 93 mmHg. The patient was on mechanical ventilation via a tracheostomy tube and showed no signs of respiratory distress or hypoxia with 40% oxygen mechanically assisted ventilation. The CVP was 15–17 cmH2O, which was at a high level. Cardiac ultrasound showed that the internal diameter of the pulmonary artery was 20 mm, with no signs of pulmonary hypertension and average size of all heart chambers. At that time, we considered that the tip of the catheter might penetrate from the subclavian vein into the subclavian artery. Because it was difficult to stop the bleeding by applying pressure to the subclavian artery, we did not dare to remove the deep vein catheter at the moment. To further determine the location of the central venous catheter, we performed a chest radiograph and enhanced CT. Chest radiographs and enhanced CT showed that the left subclavian vein catheter was not placed into the superior vena cava connected to the right atrium, but descended vertically from the left cephalic brachial vein into the left pulmonary vein. This is shown in Figures 1 and 2. Consider a PAPVR, where the left cephalic brachial vein and pulmonary vein are connected. The left subclavian vein catheter passes directly into the pulmonary vein through the left cephalic brachial vein. Therefore, the blood drawn back from the catheter is mixed with pulmonary venous blood. We found the cause and safely removed the left subclavian vein. A femoral venous catheter was placed instead.
Figure 1.
The chest radiograph showed that the left subclavian vein catheter was not placed into the superior vena cava connected to the right atrium, but descended vertically from the left cephalic brachial vein into the left pulmonary vein
Figure 2.
(a) Central venous catheter in left subclavian vein. (b) Central venous catheter in left cephalic brachial vein. (c) Central venous catheter at the lower end of the left cephalic vein. (d) Central venous catheter in partial anomalous pulmonary venous return (PAPVR). (e) Central venous catheter in left pulmonary vein. (f) No catheter at the end of left pulmonary vein.
DISCUSSION
PAPVR is a scarce congenital heart condition vascular malformation. It manifests as an abnormal blood return from one or more pulmonary veins directly to the right atrium or indirectly to the right atrium via connection with one of the proximal systemic veins. To distinguish congenital PAPVR, we must have a good grasp of the standard cardiovascular anatomy. We provide a graphical overview in Figure 3. The internal jugular vein descends to the posterior aspect of the sternoclavicular joint and joins the subclavian vein to form the cephalic brachial vein. The left and right cephalic brachial veins merge into the superior vena cava after the union of the right 1st thoracic rib. The superior vena cava enters the right atrium. The pulmonary artery emanates from the right ventricle, enters the lungs with the bronchi, branches repeatedly with the bronchi, and finally forms a capillary network around the alveoli, which then gradually converges into a pulmonary vein and flows back to the left atrium. 4 , 5
Figure 3.
This is a simplified schematic diagram of the major central veins. The dashed line in the diagram shows the abnormal pulmonary venous drainage.
Direct or indirect pulmonary venous drainage into the right atrium can increase flow to the right heart, leading to enlargement of the right atrium and dilatation of the pulmonary artery. When the abnormal venous return is less than 50% of the venous flow in the whole lung, the patient is usually asymptomatic. 3
Oxygen enters the blood through pulmonary exchange and the partial pressure of oxygen decreases from the arterial system across the capillaries to the venous system. The partial pressure of oxygen in the central veins is supposed to be lower than in the arterial system. However, in this case the partial pressure of oxygen in the blood from the central venous catheter was much higher than the partial pressure of oxygen in the peripheral arteries, suggesting that the blood drawn from the catheter tip comes from pulmonary venous blood flow, which is then mixed with systemic venous blood. 6 Some cases find that the partial pressure of oxygen (PO2) in blood from a central venous catheter placed in a PAPVR is higher than that of a radial artery specimen. This occurs when the PO2 in the other three pulmonary veins is lower than the PO2 in the PAPVR. 7
When the absence of a central venous catheter into the artery was ruled out, another explanation for the abnormally high PaO2 could be that the central venous catheter was placed in the PAPVR.
CONCLUSION
Suppose an abnormal venous catheter puncture position is encountered in clinical work. Exclude common causes such as puncture into the carotid artery and failure to reach the vessel. One of the reasons may be that the catheter has entered a PAPVR. The cause can be clarified by completing a chest radiograph or chest CT. 1 , 8
AUTHOR CONTRIBUTIONS
Ye Ruiling collects patient information and writes articles. Jiang Zhengying revised the article and pictures.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ETHICS STATEMENT
The patient gave written informed consent for publishing images.
Ye R, Jiang Z. Difficulty in central venous catheter placement due to congenital partial anomalous pulmonary venous return: a case report. Pulm Circ. 2022;12:e12157. 10.1002/pul2.12157
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