Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2020  |  Volume : 31  |  Issue : 2  |  Page : 542--544

Persistence of left superior vena cava detected during cuffed dialysis catheter insertion


Rashmi Yadav1, Urmila Anandh1, Ritesh Kumar2, Sapna Marda2,  
1 Department of Nephrology, Yashoda Hospitals, Secunderabad, Telangana, India
2 Department of Radiology, Yashoda Hospitals, Secunderabad, Telangana, India

Correspondence Address:
Urmila Anandh
Department of Nephrology, Yashoda Hospitals, Secunderabad - 500 003, Telangana
India

Abstract

Persistent left superior vena cava is a rare finding seen only in 0.3%-0.5% population. It is generally asymptomatic and is often discovered after central venous catheterization done for various indications. We present a case where we demonstrate persistent left superior vena cava/left cardinal vein remnant discovered during left-sided cuffed catheter insertion for hemodialysis in a 65-year-old chronic kidney disease patient. Findings were confirmed with computed tomography venogram. This anomaly poses iatrogenic risks to the patient if not detected early. A catheter along the left mediastinal border can be dangerously close to descending aorta and could also be indicative of its placement in the internal thoracic vein or, pericardiophrenic vein. It can also perforate the persistent/remnant vessel and enter the pleura, pericardium, or mediastinum. This case emphasizes the importance of familiarity with this entity and its role in determining the appropriate venous access for patient therapy when faced with this clinical situation.



How to cite this article:
Yadav R, Anandh U, Kumar R, Marda S. Persistence of left superior vena cava detected during cuffed dialysis catheter insertion.Saudi J Kidney Dis Transpl 2020;31:542-544


How to cite this URL:
Yadav R, Anandh U, Kumar R, Marda S. Persistence of left superior vena cava detected during cuffed dialysis catheter insertion. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Aug 7 ];31:542-544
Available from: http://www.sjkdt.org/text.asp?2020/31/2/542/284034


Full Text



 Introduction



Placement of cuffed internal jugular venous catheter (IJV) is a routine procedure in chronic kidney disease (CKD) patients as access for hemodialysis (HD). It is preferred in patients with atheromatous vessels not fit for arterio- venous fistula (AVF) creation or those in whom AVF has failed or those with multiple access failure. It is not uncommon that left-sided IJV is used for the placement of cuffed catheter either due to right IJV thrombosis, anatomical disturbance or HD catheter insertion is associated with various complications such as bleeding, pneumothorax, infection, and thrombosis, with an overall rate of 2%–10%.[1] It can further increase in cases where anatomical anomalies are present. Persistent superior vena cava (SVC) is one such anomaly found only in 0.3%-0.5% population.[2] It is generally detected during placement of left-sided central venous access. We present a similar case finding of incidental detection of persistent SVC during insertion of cuffed left-sided dialysis catheter.

 Case Report



Informed consent was obtained from the patient before presenting the report.

A 65-year-old male case of CKD Stage 5 was initiated on HD through right IJV temporary dialysis catheter about four weeks back came to us with dialysis catheter-related blood stream infection. During the last admission, when he was initiated on HD he also underwent a left radiocephalic AVF creation. At the same admission, the initial AVF did not function; hence, a brachiocephalic fistula was constructed. His right dialysis catheter was infected and was removed. As his left AVF was yet to mature, a left cuffed dialysis catheter was considered. Under ultrasound guidance, left IJV cuffed dialysis catheter was inserted. Throughout the procedure, the patient was hemodynamically stable; however, the catheter had poor flow. Post-procedure, X-ray was done, which showed the dialysis catheter along the left mediastinal border [Figure 1].{Figure 1}

The possibility of the catheter in the internal thoracic vein, pericardiophrenic vein, descending aorta, pleural space, pericardium or in the mediastinum was considered and the cuffed catheter was removed. Right IJV temporary catheter was inserted, the placement was confirmed with chest X-ray and HD was continued.

Meanwhile, the possibility of persistent SVC was also considered and a computed tomography (CT) venogram was done to look for any anomaly. The CT findings with multiplanar reconstruction [Figure 2] were suggestive of the venous channel which was likely to be persistent left SVC/left cardinal vein remnant with nonopacification/occlusion (chronic) of the distal-most segment. The echocardiogra- phy excluded any possibility of the catheter induced damage to the coronary sinus.{Figure 2}

 Discussion



Persistent SVC is the most common thoracic venous anomaly. It is present in 0.3%-0.5% of the general population and 10% in patients with cardiac anomalies.[3] During embryonic development, the bilateral cardinal veins modify and the left cardinal venous system obliterates. A new vein (future left innominate vein) drains into a right cardinal vein (future right SVC). Disturbances to this embryonic developmental stage may result in a persistent left SVC. In 70%-90% of these patients right SVC is also present.[4] The persistent left SVC commonly drains into the coronary sinus, but in up to 8% of patients, it might drain into the left atrium. In our patient, the distal segment of the anomalous vein was occluded suggestive of a rare variant.

Persistent left SVC is usually asymptomatic unless associated with cardiac anomalies. It should be suspected in patients with dilated coronary sinus as seen in two-dimensional- Echo. The diagnosis is confirmed with CT venogram or magnetic resonance imaging scan. The familiarity with this entity may help in patient therapy by deciding the placement of central venous catheters, dialysis catheters, PICC lines, or pacemakers.

 Conclusion



We present a rare case of persistent left SVC/left cardinal vein remnant in a CKD patient, in whom left cuffed dialysis catheter placement was attempted. This case emphasizes the importance of familiarity with this entity and its role in determining the appropriate venous access for patient therapy.

Conflict of interest: None declared.

References

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2Lim TC, H’ng MW. Persistent left superior vena cava: A possible site for haemodialysis catheter insertion. Singapore Med J 2010;51: 195-7
3Biffi M, Bertini M, Ziacchi M, et al. Clinical implications of left superior vena cava persistence in candidates for pacemaker or cardioverter-defibrillator implantation. Heart Vessels 2009;24:142-6
4Ramos N, Fernandez-Pineda L, Tamariz-Martel A, Villagra F, Egurbide N, Maitre MJ. Absent right superior vena cava with left superior vena cava draining to an unroofed coronary sinus. Rev Esp Cardiol 2005;58:984-7.