CLINICAL CORRESPONDENCE

Vol. 137 No. 1604 |

DOI: 10.26635/6965.6639

Persistent left superior vena cava after insertion of central venous catheter

Central venous catheter (CVC) insertion for haemodialysis (HD) is a regularly performed procedure.1 Usually, it is easily accomplished by a well-trained hand; however, it does not come without risk of complications.

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Central venous catheter (CVC) insertion for haemodialysis (HD) is a regularly performed procedure.1 Usually, it is easily accomplished by a well-trained hand; however, it does not come without risk of complications. Infection, arrythmia, thrombosis, bleeding, pneumothorax and malposition of the catheter tip are among these.2,3 The preferred access site for a non-tunnelled catheter is the right internal jugular vein due to its direct path to the superior vena cava (SVC) and right atrium. The second choice would be the left internal jugular vein. Femoral placement is an additional option but has high rates of infection and may cause loss of ambulation.4

The National Kidney Foundation recommends using arteriovenous (AV) access fistulas/grafts for HD. Eighty percent of incident HD patients still initiate dialysis with a CVC due to its ability to be used promptly in emergency situations.1,5,6 The incidence of CVC tip malposition is up to 7%. Venous anatomy variation is a contributing factor to tip malposition.7 Although persistent left superior vena cava (PLSVC) is the commonest anomaly of the thoracic venous system, it remains a rare congenital variant overall. It can, however, have a significant clinical impact.8

Case report

A 60-year-old male with chronic kidney disease stage 5 due to type 2 diabetes mellitus was seen in the outpatient dialysis unit for insertion of a non-tunnelled CVC. This was a temporary access site for HD while awaiting his left brachiocephalic AV fistula to mature. A double lumen non-cuffed HD catheter was inserted into the left internal jugular vein as the right internal jugular was found to be thrombosed on ultrasound. This was a likely outcome due to multiple previous tunnelled HD catheter placements. An uncomplicated procedure was followed by aspiration of dark red, non-pulsatile blood from the lumen. There were no signs of cyanosis, bleeding or hypotension after insertion. A routine post-procedure chest X-ray (CXR) showed an atypical position of the tip of the catheter in the left mediastinum (see Figure 1).

The patient was sent for an urgent computed tomography (CT) of the chest that revealed a catheter tip placed in a PLSVC, the drainage of which was into the right atrium via the coronary sinus, which was deemed safe for use for the purpose of HD by the radiologist on duty (see Figure 2a and 2b).

The catheter was used successfully for HD sessions until the AV fistula had reached maturity. The patient was closely monitored during HD sessions, which remained uneventful. The CVC was removed once the AV fistula was mature and successfully cannulated. With follow-up of the patient, there was no impaired venous flow to the left upper limb, and HD sessions carried out via the mature fistula remained uneventful.

View Figure 1–3.

Discussion

PLSVC is the most common congenital venous anomaly of the thoracic systemic venous return. The incidence is 0.3–0.5% of individuals in the general population and up to 12% in individuals with other documented congenital heart abnormalities.3 PLSVC results from when the left superior cardinal vein caudal to the innominate vein fails to regress8 (see Figure 3). There are several anatomical variations that occur in PLSVC. Most commonly, a PLSVC can coexist with a right SVC in 80–90% of cases. Bilateral SVCs can also vary in size to different degrees. In 65% of bilateral SVC cases, a left innominate vein is absent.3 In 80–92% of cases, the PLSVC drains into the right atrium via the coronary sinus with no resultant change in haemodynamic state, as is the case with our patient. Conversely, 10–20% of cases of PLSVC can drain into the left atrium either through the coronary sinus, the roof of the left atrium or the left superior pulmonary vein.3 Other abnormalities found concomitantly with PLSVC are atrial septal defect, ventricular septal defect, bicuspid aortic valve and aortic coarctation.9,10

There are important implications of PLSVC as it applies to cardiac venous return. Particularly, a venous return pattern where the PLSVC drains to the left atrium, and any cardiac abnormality resulting in right-to-left cardiac shunting can place patients at risk for embolic complications to the arterial system.3 Cases of supraventricular arrythmias, cardiac arrest and coronary sinus thrombosis have been reported in PLSVC after CVC.11 Therefore, one needs to characterise the venous return in a patient with known PLSVC prior to initiating use of the CVC placed within it.3

Based on the anatomical variations and the risk associated with catheterisation of a PLSVC, its safety for long-term HD use has not been accurately evaluated.11 PLSVC is, however, rarely reported, as it can go undiscovered since most dialysis catheters are inserted into the right internal jugular and venous system imaging is not routinely done prior to catheter insertion.

Although not utilised in this case, echocardiography can provide a non-invasive diagnosis of PLSVC.12 A lateral CXR can differentiate cannulation of the hemizygous or superior intercostal vein, as this has a similar presentation on antero-posterior CXR as cannulation of the PLSVC.10,12 In our case, the CVC was safely used after confirmation via CT scan that the catheter tip was in the PLSVC, and its drainage was into the right atrium.

Conclusion

Venous imaging should be considered in patients with known congenital cardiac abnormalities prior to insertion of HD catheter to confirm the presence or absence of a PLSVC. Conversely, patients that were discovered to have a PLSVC should be investigated for other cardiac anomalies. We have arranged for an outpatient echocardiogram for our case. PLSVC can be used safely for short-term HD with careful monitoring.11 Physicians placing HD catheters should be aware of the potential of a PLSVC, its diagnosis and its complications. When dealing with the accidental placement of a central catheter into a PLSVC, one should consider the reason for insertion and the condition of the patient. The risks and benefits to allow HD through a PLSVC should be considered on a patient-to-patient basis.7 In our case, access for HD was imperative and without prompt access his condition would worsen. The venous drainage of the PLSVC was confirmed via CT. Although rare, by increasing our awareness around this condition we can minimise complications and improve patient safety overall.

Authors

Nandika Muruvan: Senior House Officer, Nephrology, Palmerston North Hospital, New Zealand.

Arthur Cavan: Consultant, Medicine, Palmerston North Hospital, New Zealand.

Marilyn Aday: Nephrologist, Palmerston North Hospital, New Zealand.

Ankur Gupta: Nephrologist and Hypertension Specialist, Palmerston North Hospital, New Zealand.

Acknowledgements

We would like to acknowledge and thank Dr Barry Schmidt for his contribution toward annotation of medical images.

Correspondence

Nandika Muruvan: Senior House Officer, Palmerston North Hospital, New Zealand.

Correspondence email

nsmuruvan@gmail.com

Competing interests

Nil.

1)       Moist LM, Lok CE. Incident Dialysis Access in Patients With End-Stage Kidney Disease: What Needs to Be Improved. Semin Nephrol. 2017;37(2):151-158. doi: 10.1016/j.semnephrol.2016.12.005.

2)       Nayeemuddin M, Pherwani AD, Asquith JR. Imaging and management of complications of central venous catheters. Clin Radiol. 2013;68(5):529-44. doi: 10.1016/j.crad.2012.10.013.

3)       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 Oncol. 2011;9:173. doi: 10.1186/1477-7819-9-173.

4)       Schwab SJ, Beathard G. The hemodialysis catheter conundrum: hate living with them, but can't live without them. Kidney Int. 1999;56(1):1-17. doi: 10.1046/j.1523-1755.1999.00512.x.

5)       Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001. Erratum in: Am J Kidney Dis. 2021 Apr;77(4):551. doi: 10.1053/j.ajkd.2021.02.002.

6)       Haddad NJ, Cleef SV, Agarwal AK. Central Venous Catheters in Dialysis: the Good, the Bad and the Ugly. Open Urol Nephrol J. 2012;5(1):12-18. doi: 10.2174/1874303X01205010012.

7)       Roldan CJ, Paniagua L. Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction. West J Emerg Med. 2015;16(5):658-64. doi: 10.5811/westjem.2015.7.26248.

8)       He H, Li B, Ma Y, et al. Catheterization in a patient with end-stage renal disease through persistent left superior vena cava: a rare case report and literature review. BMC Nephrol. 2019;20(1):202. doi: 10.1186/s12882-019-1339-5.

9)       Kuppusamy TS, Balogun RA. Unusual placement of a dialysis catheter: persistent left superior vena cava. Am J Kidney Dis. 2004;43(2):365-7. doi: 10.1053/j.ajkd.2003.10.033.

10)    Kim YO, Choi EJ, Jeon HK, et al. Persistent left superior vena cava detected by hemodialysis catheterization. Nephron. 1999;83(1):87-8. doi: 10.1159/000045478.

11)    Guerrot D, Hanoy M, Godin M. Haemodialysis catheterization via type II persistent left superior vena cava. NDT Plus. 2008;1(2):100-102. https://doi.org/10.1093/ndtplus/sfm031.

12)    Stylianou K, Korsavas K, Voloudaki A, et al. Can a left internal jugular catheter be used in the hemodialysis of a patient with persistent left superior vena cava? Hemodial Int. 2007;11(1):42-5. doi: 10.1111/j.1542-4758.2007.00152.x.

13)    Demșa I, Crișu D, Haba CMȘ, et al. Persistent Left Superior Vena Cava with Absent Right Superior Vena Cava and Discrete Subaortic Stenosis Diagnosed in a Patient with Sick Sinus Syndrome: A Case Report and Brief Review of the Literature. Diagnostics (Basel). 2020 Oct 19;10(10):847. doi: 10.3390/diagnostics10100847.