Medical Image of the Week: Persistent Left Superior Vena Cava

Figure 1. Left subclavian central line courses in a left paramediastinal location.

Figure 2. Axial CT image of the chest shows a vessel coursing lateral to the aortic arch consistent with a persistent left superior vena cava.

A 19 year old man with acute lymphocytic leukemia was admitted to the ICU with septic shock. Due to areas of cellulitis on the right side of the chest and neck and femoral venous thrombi, a left subclavian central access was attempted. The chest x-ray obtained after line placement is shown below (Figure 1). Blood gas done from the line was consistent with venous blood and venous tranduction was seen. A CT of the chest (Figure 2) confirmed the diagnosis of persistent left superior vena cava (PLSVC).

A persistent left superior vena cava is the most common congenital thoracic venous anomaly, seen in 0.3-0.5% of the population (1). Incidence is increased in patients with congenital heart disease to 5%. In most patients a right sided SVC is also present; hence the term SVC duplication has also been used. Embryologically a PLSVC is formed when the left anterior cardinal vein is not obliterated during fetal development to form the ‘Ligament of Marshall’. It usually drains in to the coronary sinus.

Diagnosis is usually made incidentally on CT scan, echocardiography or,like in our case, after a left sided central access. Practically, its presence may complicate left sided central access including Swan Ganz Catheter placement, implantable cardioverter defibrillator (ICD) placement and during cardiac surgery including during administration of retrograde cardioplegia or cardiac transplant.

Emad Hammode MD¹, Khaled Hamed MD¹, Mohammad Hudeeb MD¹, Veronica Arteaga MD²

¹Department of Internal Medicine

²Department of Thoracic Imaging

University of Arizona Medical Canter

Tucson, AZ

Reference

1. 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. [CrossRef] [PubMed]

Reference as: Hammode E, Hamed K, Hudeeb M, Arteaga V. Medical image of the week: persistent left superior vena cava. Southwest J Pulm Crit Care. 2014;9(4):242-3. doi: http://dx.doi.org/10.13175/swjpcc132-14 PDF

Medical Image of the Week: Duplicate Superior Vena Cava

Figure 1. AP chest X-ray demonstrating duplicate superior vena cava (SVC) with central lines in both the right and left superior vena cava (arrows at catheter tips). The chest x-ray shows the characteristic left-sided course of the catheter passing through a persistent left SVC (straight arrow).

Figure 2. Contrast enhanced CT of chest revealing left -sided SVC (arrow).

A persistent left SVC is the most common thoracic venous anomaly and usually opens into the right atrium via the coronary sinus.  A central line inserted into the left SVC may be mistaken for placement in other sites such as the subclavian or carotid artery, the mediastinum, the pericardium or pleural space. A duplicate SVC may cause difficulty in introducing central venous catheters or pulmonary artery catheters because of the narrow opening of the coronary sinus to reach the right atrium. In addition, a duplicate SVC is associated with important cardiac conditions such as atrial septal defects and ventricular arrhythmias.

Dena L’Heureux MD, Josh Malo MD and Linda Snyder MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona

Tucson, AZ

Reference as: L'Heureux D, Malo J, Snyder L. Medical image of the week: duplicate superior vena cava. Southwest J Pulm Crit Care. 2013;6(4):178-9. PDF