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Accidental Cannulation of Persistent Left Superior Vena Cava in a Case of Absent Right Internal Jugular Vein: A Case Report on the Role of Ultrasonography and X-Ray

Sonawane, Nilesh B. DNB, DA*; Shah, Falguni Rajendra MD, DNB, FCPS, DA; Gawankar, Prakash Jagadish MD, DA

doi: 10.1213/XAA.0000000000000505
Case Reports: Case Report
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Persistent left superior vena cava is a rare vascular anatomical variant. Although ultrasonography has facilitated the process of central venous catheterization, it cannot be used to locate the tip of a catheter. Postprocedure chest X-ray is desirable for locating the course and tip of the catheter. In our case, initial ultrasonography demonstrated the absence of the right internal jugular vein. This prompted insertion of a central venous catheter on the left side of the neck in the presence of normal vascular anatomy. A subsequent chest X-ray revealed an abnormal course of the catheter consistent with presence of persistent left superior vena cava.

From the *Department of Anaesthesia and Intensive Care, Barnet Hospital, London, United Kingdom; and Department of Anaesthesia, Lilavati Hospital and Research Centre, Bandra (West), Mumbai, India.

Accepted for publication December 22, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Nilesh B. Sonawane, DNB, DA, Flat 23, Girton court, 7, Magdalene Gardens, Whetstone, London N20 0AF, UK. Address e-mail to sonawanenilesh805@gmail.com.

Central venous catheter (CVC) placement frequently is used for therapeutic or diagnostic purposes. National Institute of Clinical Excellence guidelines recommend the use of ultrasonography during CVC placement.1 The incidence of complications associated with CVC cannulation (eg, arterial puncture, bleeding, pneumothorax, cardiac arrhythmias, thrombosis, infection) is as high as 33%,2 and the probability of complications increases with obesity, anatomical variants of internal jugular vein and carotid artery, thrombocytopenia, anticoagulation, previous CVC insertion, and operator inexperience.3

Thus, identification of vascular anatomical variants is important in improving the safety of CVC insertion. Here, we report a case of absent right internal jugular vein and persistent left superior vena cava (PLSVC).

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Consent Statement

Written permission for publication of this case report was obtained from patient.

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CASE REPORT

A 36-year-old woman with carcinoma of adnexal mass with American Society of Anesthesiologists physical status I was scheduled for tumor mass resection via laparotomy. The mass invaded the sigmoid colon, ureter, and the urinary bladder. Medical history and functional status were unremarkable. All biochemical markers and electrocardiogram were within normal limits. After induction of general anesthesia and endotracheal intubation, we scanned the right neck with a 7- to 14-Hz frequency ultrasound probe in preparation of right-sided internal jugular venous cannulation. Surprisingly, we could not identify the internal jugular vein. Instead, we could only see small venous channels next to the carotid artery (Figure 1). Subsequent scanning of the left neck revealed a normal anatomy of internal jugular vein and carotid artery (Figure 2). Puncture of the left internal jugular vein, insertion of the guidewire, and cannulation were uneventful. No cardiac arrhythmias were observed. An X-ray done after completion of surgery (Figure 3) revealed an abnormal course of the CVC straight down the left parasternal border.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Figure 4.

Figure 4.

Because the patient was to be scheduled for chemoport insertion at a later date, we decided to evaluate her vascular anatomy. A 2-dimensional transthoracic echocardiogram revealed a dilated coronary sinus. No other anatomical or functional abnormalities were detected. A magnetic resonance imaging venogram confirmed the presence of PLSVC and hypoplastic right internal jugular vein with multiple small venous channels on the right side of neck (Figure 4). It was not possible to identify the exact location of the drainage of the PLSVC; however, the dilated coronary sinus seen on the 2-dimensional transthoracic echocardiogram was suggestive of PLSVC draining into the right atrium.

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DISCUSSION

The thoracic venous drainage system often is associated with various anomalies. PLSVC is one such commonly encountered anomaly. Its incidence is 0.5% among the general population and increases up to 10% in patients with congenital heart diseases.4 Incidence of congenital heart diseases is more when left superior vena cava drains into left atrium.

During embryonic development,5 the venous system has 2 superior (anterior) and 2 inferior (posterior) cardinal veins that return blood from the superior and inferior parts of the body, respectively (Figure 5). Both pairs of vein join to form the right and left common cardinal veins before entering the primitive heart. The left common cardinal vein forms the oblique vein of the left atrium and the coronary sinus. The right and left superior cardinal veins form the innominate vein. The cranial part of the right superior cardinal vein transforms into the right internal jugular vein, whereas its caudal part transforms into the right superior vena cava. By contrast, the part of the left superior cardinal vein proximal to the innominate vein forms the left internal jugular vein, whereas its distal part regresses to form the “ligament of Marshall.”

Figure 5.

Figure 5.

If this regression does not occur, it results in a persistent left-thoracic vascular structure like PLSVC that mostly empties into the coronary sinus. The left superior vena cava runs vertically to the left of the aortic arch and main pulmonary artery and along the left atrium. It then turns medially, pierces the pericardium, and stays in the atrioventricular groove. In 90% of cases, the PLSVC drains into the coronary sinus, causing it to dilate. In remaining 10% of the cases, the PLSVC drains into the inferior vena cava or hepatic vein or left atrium. If the CVC runs along the left mediastinal border, one should suspect the presence of PLSVC. In such a case, the CVC may be in the descending aorta, superior intercostal vein, pleura, pericardium, or mediastinum. Chest X-ray, blood gas analysis showing venous values, and a venous pressure waveform usually allow the diagnosis of PLSVC. Computed tomography scan, 3-dimensional contrast-enhanced magnetic resonance venogram, and 2-dimensional transthoracic echocardiography are additional diagnostic tools.

PLSVC draining into the right atrium via coronary sinus is associated with the risk of cardiac perforation during CVC insertion.6 Underlying PLSVC during cardiopulmonary bypass may lead to ineffective retrograde cardioplegia.7 Complications also have been reported during transvenous pacing for bradycardia and during implantation of an automated internal cardioverter defibrillator.8,9 Patients with PLSVC should be evaluated for the presence of any coexisting congenital cardiac defects like atrial septal defect, ventricular septal defect, tetralogy of Fallot, endocardial cushion defects, and cor triatriatum. PLSVC that drains into the left atrium will result in a right-to-left shunt, leading to cyanosis and risk of paradoxical embolism.4

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CONCLUSIONS

Venous anomalies frequently are encountered in daily practice. Our case re-emphasizes the importance of using ultrasound during CVC placement. It enabled the immediate diagnosis of an absent right internal jugular vein. Because ultrasonography does not allow identification of the tip of a CVC, a chest X-ray after CVC insertion may be advisable for such purpose.

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DISCLOSURES

Name: Nilesh B. Sonawane, DNB, DA.

Contribution: This author helped conceive and design the study, search the literature, and prepare the manuscript.

Name: Falguni Rajendra Shah, MD, DNB, FCPS, DA.

Contribution: This author helped search the literature, edit the manuscript, and with intellectual content.

Name: Prakash Jagadish Gawankar, MD, DA.

Contribution: This author helped design the study, search the literature, edit the manuscript, and with intellectual content.

This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.

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REFERENCES

1. National Institute of Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters, 2002. Available at: https://www.nice.org.uk/guidance/ta49. Accessed May 10, 2016.
2. Fares WH, Birchard KR, Yankaskas JR. Persistent left superior vena cava identified during central line placement: a case report. Respir Med CME2011;4:141143.
3. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10:R162.
4. Povoski SP, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol2011;9:173.
5. Goyal SK, Punnam SR, Verma G, Ruberg FL. Persistent left superior vena cava: a case report and review of literature. Cardiovasc Ultrasound2008;6:50.
6. Azocar RJ, Narang P, Talmor D, Lisbon A, Kaynar AM. Persistent left superior vena cava identified after cannulation of the right subclavian vein. Anesth Analg. 2002;95:305307.
7. Hanson EW, Hannan RL, Baum VC. Pulmonary artery catheter in the coronary sinus: implications of a persistent left superior vena cava for retrograde cardioplegia. J Cardiothorac Vasc Anesth1998;12:448449.
8. Chaithiraphan S, Goldberg E, Wolff W, Jootar P, Grossman W. Massive thrombosis of the coronary sinus as an unusual complication of transvenous pacemaker insertion in a patient with persistent left, and no right superior vena cava. J Am Geriatr Soc1974;22:7985.
9. Markewitz A, Mattke S. Right ventricular implantable cardioverter defibrillator lead implantation through a persistent left superior vena cava. Pacing Clin Electrophysiol1996;19:13951397.
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