Persistent Left Superior Vena Cava Identified After Cannulation of the Right Subclavian Vein : Anesthesia & Analgesia

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CARDIOVASCULAR ANESTHESIA: Case Report

Persistent Left Superior Vena Cava Identified After Cannulation of the Right Subclavian Vein

Azocar, Ruben J. MD; Narang, Punam MD; Talmor, Daniel MD; Lisbon, Alan MD; Murat Kaynar, A. MD

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doi: 10.1213/00000539-200208000-00009
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Central venous cannulation is a common procedure in the intensive care unit (ICU). It is performed for pressure monitoring and the administration of fluids, medications, and parenteral nutrition. After the insertion of a central venous catheter (CVC), a chest radiograph is routinely obtained to determine the correct placement of the catheter and to exclude pneumothorax or hemothorax.

We present a case in which a CVC was placed with ease into the right subclavian vein and the tip of the catheter was noted to be in the left side of the mediastinum on the postprocedure chest radiograph.

Case Report

A 51-yr-old man was admitted to the surgical ICU after a motor vehicle accident. His medical history was significant only for hypertension and alcohol abuse.

After admission to the ICU, it was decided to place a CVC for IV access. A right subclavian line was placed with no apparent difficulty. No pulsatile blood or high pressure back flow was noted during the procedure and the blood was dark, as expected in a venous puncture. The postprocedure chest radiograph was obtained (Fig. 1) and read by the radiologist as: “Right subclavian central line, which courses across the midline and extends towards the left suprahilar region. Its course is unusual, and suggests either penetration of the vein wall or possible intra-aortic location. No pneumothorax is seen.”

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Figure 1:
Chest radiograph after central venous catheter (CVC) insertion showing the catheter crossing the midline. The arrow indicates the CVC tip.

A pressure tracing demonstrated a typical central venous pressure waveform. A blood gas analysis was consistent with venous blood. Subsequent fluoroscopic images with contrast suggested the presence of a persistent left superior vena cava (SVC) (Fig. 2). A computer tomography of the chest confirmed our finding and showed that the persistent left SVC was draining into the right atrium via the coronary sinus (Figs. 3 and 4).

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Figure 2:
Fluoroscopic image of contrast injected via the central venous catheter, showing filling of the superior vena cava and right atrium.
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Figure 3:
Computer tomography-angio-gram of the chest demonstrating the left-sided persistent superior vena cava.
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Figure 4:
Reconstructed computer tomography scan image of contrast-filled left-sided persistent superior vena cava draining into the coronary sinus.

The CVC was left in situ and used without any problems. An echocardiographic study of the heart did not reveal any other congenital anomalies.

Discussion

During central venous cannulation, the reported incidence of inadvertent arterial puncture varies. In a study of 6245 patients who underwent central venous cannulation for placement of pulmonary artery catheter, Shah et al. (1) reported an incidence of arterial puncture of 1.9%. Intraarterial placement of the catheters was recognized by high pressure back flow and all were removed without any complications. Mansfield et al. (2) reported on 821 patients undergoing central venous cannulation through the subclavian vein. The incidence of arterial puncture was 3.7%. However, other authors have reported an incidence of arterial puncture as frequent as 9%(3). Additional sites of mediastinal central line malposition include cannulation of the left internal mammary, left superior intercostal vein, and the pericardiophrenic veins.

Intraarterial insertion of a catheter may lead to thrombus formation and embolization. Hence, the catheter should be removed as soon as possible. Removal and application of pressure is usually enough to control the bleeding. Neck hematoma and arterial repair have been described (4). Hemothorax has also been reported after carotid and subclavian artery cannulation (5). Neurologic complications caused by placement and subsequent use of lines in the arterial central system have also been described (6). The incidence of arterial puncture is increased in patients in whom placement was difficult and is related to the number of attempts (2). In our case, catheter insertion was easy. The blood withdrawn was dark, suggestive of venous origin, and under low pressure. Therefore, we did not suspect arterial puncture.

Persistence of the left SVC is a relatively common anomaly, reported to be present in 0.1% to 0.2% of the normal population and in 2% to 9% of patients with congenital cardiac anomalies (7,8).

Embryologically, failure of the left common cardinal vein to obliterate leads to a persistent left SVC (7). This anomalous vessel travels in the anterior aspect of the aortic arch, the left pulmonary artery, and vein. It then enters the pericardium in the posterior atrioventricular groove, draining into the right atrium via the coronary sinus, which becomes enlarged (9). Diagnosis of persistent left SVC is difficult in the absence of other anomalies. Physical examination is unremarkable. On the electrocardiogram, left axis deviation may be noted. Chest radiograph may show an unusual vertical left upper mediastinal silhouette.

Persistent left SVC does not, in itself, produce any physiologic derangement. However, in 46% of patients, it will be associated with other malformations such as situs inversus or tetralogy of Fallot (8). Patients with persistent left SVC should undergo further diagnostic studies to eliminate other cardiac anomalies. Insertion of a guide wire and subsequent cannulation of a persistent left SVC can lead to advancement into the coronary sinus. Arrhythmias, perforation of the heart, and tamponade may all subsequently be observed.

In our case, after reviewing the chest radiograph, the radiologist diagnosed an arterial cannulation with the catheter tip in the aorta. Transducing the pressure and obtaining blood gas analysis seemed to confirm venous placement. Injection of contrast dye via the catheter (Fig. 2) and computer tomography of the chest allowed us to diagnose a persistent left SVC with an absent right SVC. The persistent left SVC was draining into the right atrium via an enlarged coronary sinus (Figs. 3 and 4). Atrial electrocardiography is an additional noninvasive method of confirming central line placement. Lack of an atrial pattern tracing on an electrocardiogram leads to a suspicion of a malpositioned catheter. In our case, although this was not attempted, atrial electrocardiography would be unlikely to have diagnosed a persistent left SVC because the catheter tip was in the right atrium. Cardiac echocardiography did not reveal any further cardiac anomaly and confirmed the enlargement of the coronary sinus.

The CVC was used for four days, until no longer needed. No complications derived from the use of the CVC in this persistent left SVC vein.

This case presents an interesting diagnostic dilemma and an anatomical entity of which anesthesiologists and intensivists alike should be aware.

References

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