An unexpected CXR finding after central line insertion
London, UK
* E-mail: diprivan{at}doctors.org.uk
Editor—We wish to describe a procedure involving routine ultrasound-guided left internal jugular (LIJ) line placement, followed by an abnormal post-line insertion chest X-ray (CXR).
A 44-yr-old man was admitted to our intensive care unit after bilateral nephrectomy for adult polycystic kidney disease (APKD). Surgery was uneventful. A right internal jugular (RIJ) line was placed after induction of anaesthesia, and the postoperative CXR was unremarkable, with an acceptable final line tip position. After an uneventful initial 48-h postoperative course, the RIJ line was removed. The patient continued to receive haemodialysis via a right subclavian Tessio line. Postoperative day 3 was complicated by sepsis and fast atrial fibrillation (rate 140–160 min–1). As a result, to aid subsequent management, a decision was taken to re-insert a central line. An ultrasound-guided LIJ line was sited uneventfully, and a good central venous pressure (CVP) waveform trace was obtained, with an initial CVP of 10 cmH2O. However, subsequent CXR showed the LIJ line tip appearing to enter the left heart (right subclavian Tessio line also seen on the CXR entering the right heart) (Fig. 1). A blood sample was taken from the LIJ line and blood gas analysis confirmed venous blood.
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A trans-thoracic echocardiogram was performed and revealed the diagnosis of a persistent left superior vena cava (PLSVC).
In the normal heart, the superior and inferior vena cava, along with the coronary sinus, have a characteristic arrangement with the right atrium. PLSVC is the most common form of anomalous venous drainage involving the SVC and represents persistence of the left horn of the embryonic sinus venosus, which normally involutes during normal development to become the coronary sinus.1 Almost always, a PLSVC enters the right atrium through the orifice of an enlarged coronary sinus and is, therefore, considered to be an anomaly of the coronary sinus.2 It commences at the junction of the left internal jugular vein and left subclavian vein, characteristically reaching the heart in the angle between the left atrial appendage and the left pulmonary veins, then running down the back of the left atrium to enter the left atrio-ventricular groove and channel draining blood from the head and the left upper limb. PLSVC has an incidence rate of 0.3–0.5% of the normal population and rising to 3–10% of patients with other congenital cardiac malformations.3 When it is not associated with other cardiac malformations, it is usually asymptomatic and haemodynamically insignificant. However, PLSVC does have important clinical implications in certain situations as it may complicate placement of cardiac catheters or pacemaker leads4 and awareness of this anomaly may reduce confusion about the position of catheters/leads that appear misplaced on conventional imaging.
References
1 Congenital anomalies of vena caval connection. In Perloff JK (Ed.). The Clinical Recognition of Congenital Heart Disease (1994) 4th (W. B. Saunders, Philadelphia) pp. 703–14.
2 Gonzalez-Juanatey C, Testa A, Vidan J, et al. (2004) Persistent left superior vena cava draining into the coronary sinus: report of 10 cases and literature review. Clin Cardiol 27:515–8.[Web of Science][Medline]
3 Pahwa R and Kumar A. (2003) Persistent left superior vena cava: an intensivist's experience and review of the literature. South Med J 96:528–9.[CrossRef][Web of Science][Medline]
4 Biffi M, Boriani G, Frabeti L, et al. (2001) Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-defibrillator implantation: a 10-year experience. Chest 120:139–44.
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