The Journal of Emergency Medicine, Vol. 46, No. 4, pp. e131–e132, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.09.019
Visual Diagnosis in Emergency Medicine
A CURIOUS CHEST RADIOGRAPH AFTER LINE PLACEMENT Joseph Shiber, MD, FAAEM* and Andrew Schmidt, DO† *Department of Emergency Medicine and Critical Care, and †Department of Emergency Medicine, University of Florida – College of Medicine, Jacksonville, Florida Reprint Address: Joseph Shiber, MD, FAAEM, Department of Emergency Medicine and Critical Care, University of Florida – College of Medicine, 655 W. Eighth St., Jacksonville, FL 32209
commonly occurs in isolation, but 10–40% of the time is associated with other cardiac abnormalities such as atrial or ventricular septal defects, bicuspid aortic valve, or coarctation of the aorta (2–4). The vast majority (90%) of PLSVCs drain into the right atrium via the coronary sinus or connect to a right SVC (RSVC) prior to emptying into the right atrium; 10% of PLSVCs drain into the left atrium (3,4). Over 80% of PLSVCs have an RSVC also present, although it may be small or atrophic (2). PLSVC is usually asymptomatic and hemodynamically insignificant if not associated with other cardiac anomalies (1–4). It can cause persistent hypoxemia if the PLSCV drains into the left atrium due to right-to-left shunt physiology (3). PLSVC is also associated with an
CASE REPORT A 66-year-old woman presented with fever, dyspnea, and diffuse weakness. She was febrile, tachycardic, and hypotensive, requiring central venous access for fluid resuscitation, vasopressor administration, and invasive hemodynamic monitoring. A left internal jugular catheter was placed under direct ultrasound guidance with return of nonpulsatile blood. The chest radiograph showed the catheter tip terminating to the left of her mediastinum (Figure 1). A normal central venous pressure waveform and venous blood gas result were present. It was subsequently determined from previous computed tomography of her chest that the patient had a duplicate superior vena cava (SVC), with her right side being atrophic and her left-sided SVC being dominant (Figures 2, 3). Because the catheter was indeed in her distal SVC, it was left in place and utilized. DISCUSSION A persistent left superior vena cava (PLSVC) is the most common thoracic venous abnormality, occurring in 0.3– 0.5% of the general population (1,2). The incidence increases to 2–10% if other congenital cardiac anomalies are present (3–5). PLSVC was first described in the literature in 1965 (5). It occurs due to failure of the left superior cardinal vein to regress (2,3,5). PLSVC most
Figure 1. Chest radiograph showing catheter from the left neck terminating on the left of the mediastinum (arrow head).
RECEIVED: 19 December 2012; FINAL SUBMISSION RECEIVED: 13 September 2013; ACCEPTED: 17 September 2013 e131
e132
J. Shiber and A. Schmidt
Figure 2. Computed tomogram of the chest with intravenous contrast demonstrating contrast within the proximal leftsided superior vena cava (arrow head), and left subclavian vein (X).
Figure 3. Computed tomogram of the chest with intravenous contrast demonstrating contrast within the distal left-sided SVC (arrow head), the main pulmonary artery (X) and descending aorta (Y).
increased incidence of cardiac dysrhythmias, including atrioventricular (AV) re-entry supraventricular tachycardia, sick sinus syndrome, and sinus bradycardia thought to be due to coronary sinus enlargement causing stretching and fragmentation of conducting tissue at the sinus node, AV node, and His bundle (4). PLSVC is typically found incidentally by the characteristic chest radiograph after insertion of a central venous or pulmonary artery catheter via the left internal jugular or subclavian vein (1,2). It can be suspected by the physical examination finding of left jugular venous pulsations or the presence of a dilatated coronary sinus by echocardiography (2,3). PLSVC can be confirmed by noninvasive or invasive studies such as contrast echocardiography, computed tomography with intravenous contrast, magnetic resonance imaging, and venography (1,2). It can be difficult to access the right heart from a leftsided venous approach for a central venous catheter, pulmonary artery catheter, or permanent pacemaker lead; it should be noted that catheter manipulation of the coronary sinus has resulted in bradycardia, hypotension, and cardiac arrest (4). The most common complication from central venous catheter placement in someone with PLSVC is actually the incorrect assumption that an iatrogenic injury may have occurred when the chest radio-
graph is viewed, because it may appear that the catheter is in the left carotid artery, the mediastinum, the left internal mammary vein, the pericardium, or the pleural space (2). There may be a delay in the administration of fluids, blood products, or medications while diagnostic testing is done to confirm the catheter’s exact location; the catheter may be removed, which then exposes the patient to the risks of a subsequent procedure to place another catheter. Aspiration of blood from the catheter excludes nonvascular placement while transducing a venous pressure waveform, and assaying an appropriate venous blood gas excludes arterial placement (2).
REFERENCES 1. Sarodia BD, Stoller JK. Persistent left superior vena cava: case report and literature review. Respir Care 2000;45:411–6. 2. Danielpour PJ, Aalberg JK, El-Ramey M, et al. Persistent left superior vena cava: an incidental finding during central venous catheterization. Vasc Endovasc Surg 2005;39:109–11. 3. Goyal SK, Punman SR, Verma G, et al. Persistent left superior vena cava: a case report and review of literature. Cardiovasc Ultrasound 2008;6:50–3. 4. Recupero A, Pugliatti P, Rizzo F, et al. Persistent left-sided superior vena cava: integrated noninvasive diagnosis. Echocardiography 2007;24:982–6. 5. Chen H, Shomura S, Emura S. Bilateral thoracic ducts with coexistent persistent left superior vena cava. Clin Anat 2006;19:350–3.
http://dx.doi.org/10.1016/j.jemermed.2013.09.019
Visual Diagnosis in Emergency Medicine
A CURIOUS CHEST RADIOGRAPH AFTER LINE PLACEMENT Joseph Shiber, MD, FAAEM* and Andrew Schmidt, DO† *Department of Emergency Medicine and Critical Care, and †Department of Emergency Medicine, University of Florida – College of Medicine, Jacksonville, Florida Reprint Address: Joseph Shiber, MD, FAAEM, Department of Emergency Medicine and Critical Care, University of Florida – College of Medicine, 655 W. Eighth St., Jacksonville, FL 32209
commonly occurs in isolation, but 10–40% of the time is associated with other cardiac abnormalities such as atrial or ventricular septal defects, bicuspid aortic valve, or coarctation of the aorta (2–4). The vast majority (90%) of PLSVCs drain into the right atrium via the coronary sinus or connect to a right SVC (RSVC) prior to emptying into the right atrium; 10% of PLSVCs drain into the left atrium (3,4). Over 80% of PLSVCs have an RSVC also present, although it may be small or atrophic (2). PLSVC is usually asymptomatic and hemodynamically insignificant if not associated with other cardiac anomalies (1–4). It can cause persistent hypoxemia if the PLSCV drains into the left atrium due to right-to-left shunt physiology (3). PLSVC is also associated with an
CASE REPORT A 66-year-old woman presented with fever, dyspnea, and diffuse weakness. She was febrile, tachycardic, and hypotensive, requiring central venous access for fluid resuscitation, vasopressor administration, and invasive hemodynamic monitoring. A left internal jugular catheter was placed under direct ultrasound guidance with return of nonpulsatile blood. The chest radiograph showed the catheter tip terminating to the left of her mediastinum (Figure 1). A normal central venous pressure waveform and venous blood gas result were present. It was subsequently determined from previous computed tomography of her chest that the patient had a duplicate superior vena cava (SVC), with her right side being atrophic and her left-sided SVC being dominant (Figures 2, 3). Because the catheter was indeed in her distal SVC, it was left in place and utilized. DISCUSSION A persistent left superior vena cava (PLSVC) is the most common thoracic venous abnormality, occurring in 0.3– 0.5% of the general population (1,2). The incidence increases to 2–10% if other congenital cardiac anomalies are present (3–5). PLSVC was first described in the literature in 1965 (5). It occurs due to failure of the left superior cardinal vein to regress (2,3,5). PLSVC most
Figure 1. Chest radiograph showing catheter from the left neck terminating on the left of the mediastinum (arrow head).
RECEIVED: 19 December 2012; FINAL SUBMISSION RECEIVED: 13 September 2013; ACCEPTED: 17 September 2013 e131
e132
J. Shiber and A. Schmidt
Figure 2. Computed tomogram of the chest with intravenous contrast demonstrating contrast within the proximal leftsided superior vena cava (arrow head), and left subclavian vein (X).
Figure 3. Computed tomogram of the chest with intravenous contrast demonstrating contrast within the distal left-sided SVC (arrow head), the main pulmonary artery (X) and descending aorta (Y).
increased incidence of cardiac dysrhythmias, including atrioventricular (AV) re-entry supraventricular tachycardia, sick sinus syndrome, and sinus bradycardia thought to be due to coronary sinus enlargement causing stretching and fragmentation of conducting tissue at the sinus node, AV node, and His bundle (4). PLSVC is typically found incidentally by the characteristic chest radiograph after insertion of a central venous or pulmonary artery catheter via the left internal jugular or subclavian vein (1,2). It can be suspected by the physical examination finding of left jugular venous pulsations or the presence of a dilatated coronary sinus by echocardiography (2,3). PLSVC can be confirmed by noninvasive or invasive studies such as contrast echocardiography, computed tomography with intravenous contrast, magnetic resonance imaging, and venography (1,2). It can be difficult to access the right heart from a leftsided venous approach for a central venous catheter, pulmonary artery catheter, or permanent pacemaker lead; it should be noted that catheter manipulation of the coronary sinus has resulted in bradycardia, hypotension, and cardiac arrest (4). The most common complication from central venous catheter placement in someone with PLSVC is actually the incorrect assumption that an iatrogenic injury may have occurred when the chest radio-
graph is viewed, because it may appear that the catheter is in the left carotid artery, the mediastinum, the left internal mammary vein, the pericardium, or the pleural space (2). There may be a delay in the administration of fluids, blood products, or medications while diagnostic testing is done to confirm the catheter’s exact location; the catheter may be removed, which then exposes the patient to the risks of a subsequent procedure to place another catheter. Aspiration of blood from the catheter excludes nonvascular placement while transducing a venous pressure waveform, and assaying an appropriate venous blood gas excludes arterial placement (2).
REFERENCES 1. Sarodia BD, Stoller JK. Persistent left superior vena cava: case report and literature review. Respir Care 2000;45:411–6. 2. Danielpour PJ, Aalberg JK, El-Ramey M, et al. Persistent left superior vena cava: an incidental finding during central venous catheterization. Vasc Endovasc Surg 2005;39:109–11. 3. Goyal SK, Punman SR, Verma G, et al. Persistent left superior vena cava: a case report and review of literature. Cardiovasc Ultrasound 2008;6:50–3. 4. Recupero A, Pugliatti P, Rizzo F, et al. Persistent left-sided superior vena cava: integrated noninvasive diagnosis. Echocardiography 2007;24:982–6. 5. Chen H, Shomura S, Emura S. Bilateral thoracic ducts with coexistent persistent left superior vena cava. Clin Anat 2006;19:350–3.
