Variant thoracic venous drainage and its hazards with catheter for haemodialysis.

Abstract

A 63-year-old man commenced haemodialysis for acute-on-chronic kidney disease following urgent coronary artery bypass grafting on a background history of type 2 diabetes mellitus and hypertension. Following initial treatment with a temporary dialysis catheter placed into the right femoral vein, a dual-lumen permanent catheter (Tesio line) was placed via the left internal jugular vein. The left internal jugular vein was punctured under ultrasound guidance and the line was inserted without any difficulty. There was a good flow in both lumens. A routine post-insertion chest radiograph was performed (Figure 1). Fig. 1. Post-dialysis line insertion. Chest X-ray, postero-anterior view. The line goes into left internal jugular vein and left-sided brachiocephalic vein, but then remains in the left haemithorax on the chest radiograph. The tips of the line lie at a point ... We reasoned that the usual left-sided internal jugular line goes into the left internal jugular vein, left-sided brachiocephalic vein and then crosses the midline at the upper border of the first right costal cartilage to enter the superior vena cava (SVC) on the right-hand side of the chest radiograph. The tips should lie at the level of the atrialcaval junction and ∼4 cm beyond this into the right atrium. In this case, the line did not cross the midline and looked like a mirror image of a right-sided jugular line. A venogram was requested to confirm the line position (Figure 2). This venogram confirmed that there was a persistent left-sided SVC and the line tips were in this vessel. Fig. 2. Venogram demonstrating the line position and persistent left-sided SVC. Contrast injection showed variant drainage of the neck and arm veins with right and left brachiocephalic veins dividing to drain into a normally placed right SVC and a persistent ... Discussion A persistent left-sided SVC is seen in 0.3–0.5% of the normal population and in 3–5% of those with congenital heart disease [1–3]. It is only seen in isolation in 10% of cases since the vast majorities are accompanied by a normal right-sided SVC, termed SVC duplication. Left-sided SVC forms when the left anterior cardinal vein is not obliterated during normal fetal development. The persistent left-sided SVC passes anterior to the left hilum and lateral to the aortic arch before rejoining the circulatory system. There are a number of possible drainage sites: Coronary sinus (92%), which is functionally insignificant since the venous return from the head, neck and upper limbs is delivered to the right atrium (Figure 3) [1]. This anomaly is usually asymptomatic and does not require treatment unless accompanied by other cardiac anomalies [2–4]. Fig. 3. Anatomical representation of normal thoracic venous drainage on the left and an abnormal rare variant—persistent left-sided superior vena cava draining directly into the coronary sinus on the right (reproduced with permission from: Indian Pacing ... Left atrium (8%) results in a right to left shunt which is usually not large enough to cause cyanosis or other symptoms [1, 2].