Pericardiophrenic Vein Research Articles

Persistent left superior vena cava identified during central line placement: A case report

INTRODUCTION: A persistent left superior vena cava is found in 0.3-0.5% of the general population and in up to 10% of patients with a congenital cardiac anomaly. It is the most common thoracic venous anomaly and is usually asymptomatic. Being familiar with such anomaly could help clinicians avoid complications during placement of central lines, Swan-Ganz catheters, PICC lines, dialysis catheters, defibrillators, and pacemakers. CASE PRESENTATION: We describe a case of persistent left superior vena cava that was noted after placement of a central line. Mr JJ is a 41 year old African American man who was hospitalized for evaluation and management of alcoholic necrotizing pancreatitis. He required multiple central lines placements. He was noted to have a persistent left superior vena cava that was not recognized initially and thus lead to an unnecessary extra central line placement. DISCUSSION: This anatomic variant may pose iatrogenic risks if it is not recognized by the clinician. A central catheter that tracks down the left mediastinal border may also be in the descending aorta, internal thoracic vein, superior intercostal vein, pericardiophrenic vein, pleura, pericardium, or mediastinum. CONCLUSION: Our case is significant because the patient had two extra central venous catheter placements. This case strongly demonstrates the importance of knowing the thoracic venous anomalies.

Anatomical Variations of the Left Pericardiophrenic Vein and Related Vein Structures

Introduction: Very little literature exists describing the anatomical variations of the pericardiophrenic veins (PPVs). Understanding their anatomical variations is of increasing clinical importance due to the emergence of potential new transvenous therapies and diagnostic procedures that seek to utilize these vessels. Methods: Dissection was conducted to expose the superior aspect of the PPVs and related vascular anatomy in 48 human cadavers (23 male, 25 female, mean age = 76.8 ± 14.3 years, mean body mass index = 22.8 ± 4.1 kg/m2).

Comparison of Right and Left Unilateral Phrenic Nerve Stimulation in the Termination of Central Apnea Events

Background: Central sleep apnea (CSA) is often present in patients with heart failure (HF) and has been associated with an increase in mortality. Unilateral phrenic nerve stimulation (PNS) can be used to modulate diaphragmatic contraction and affect breathing; research suggests that transvenous PNS can positively affect CSA. We hypothesized that unilateral PNS applied on either the left or the right side would have similar effects on the reduction of CSA events. Methods: Ten patients (EF = 24 ± 7%, AHI = 24.1 ± 12.1 events/hour) underwent acute placement of one of two novel stimulation leads into either the right brachiocephalic vein or the left pericardiophrenic vein.

Cardiac tamponade associated with a peripheral vein central venous catheter

We present a case of cardiac tamponade associated with placement of a central venous catheter (CVC) via a peripheral vein in a 14-year-old girl with idiopathic scoliosis undergoing corrective surgery. A number of complications have been described in association with CVC misplacement. Sporadic cases of cardiac tamponade from this have been reported, but the actual incidence is unknown. Death from cardiac tamponade attributed to CVCs ranges from 65 to 100%. In our patient, cannulation of the pericardiophrenic vein was probably the cause of cardiac tamponade, based on radiological evidence that the initial location of the catheter was near the right atrium and possibly at the outlet of the pericardiophrenic vein. The catheter could have advanced into the vein and then to the pericardial sac with postural changes. The acute clinical course of cardiac tamponade in our patient had potentially lethal hemodynamic repercussions. The main diagnostic test for this condition is echocardiography and the only effective treatment is drainage of the pericardial effusion. Echocardiography should be performed before pericardiocentesis except in life-threatening situations or high clinical suspicion. Although they are rare, it is important to be aware of the potential for CVC complications.

Beyond Coronary Sinus Angiography: The Value of Coronary Arteriography and Identification of the Pericardiophrenic Vein During Left Ventricular Lead Placement

The purpose of this study was to define the role coronary arteriography (venous phase) for improving the success of left ventricular (LV) lead implantation and to define the value of identifying the pericardiophrenic vein for optimal LV lead placement in biventricular (bi-v) device implantation. Seventy-seven patients underwent bi-v device implantation between July 2002 and October 2003. If the coronary sinus (CS) could not be accessed, then left coronary arteriography was performed during the same procedure. CS access was guided by venous phase images of the coronary arteriogram. The pericardiophrenic vein was identified by selective cannulation or direct visualization. Patients with Cr > 1.5 had gadolinium used as the contrast agent. Seventy-five successful implants were performed (97%). In seven patients (9%) repeated attempts at retrograde cannulation of the CS failed (attempt time 130 +/- 20 minute, mean +/- SD). In these patients, coronary arteriography helped define the location of the CS, which was subsequently successfully cannulated. In six patients the pericardiophrenic vein was identified either during occlusion venography of the CS (postthoracotomy, veno-venous collaterals, n = 2) or during selective cannulation of the pericardiophrenic vein (using a DAIG Csl catheter, n = 4). The vein was directly visualized in three patients who underwent surgical LV lead implantation. LV leads in all these cases were implanted in areas not overlying the preidentified pericardiophrenic vein. During follow-up, none of these patients had evidence of phrenic nerve stimulation. Intraoperative left coronary arteriography increases the success of CS cannulation. Identification of the pericardiophrenic vein is a useful method to avoid phrenic nerve stimulation.

Varicose pericardial vein: An unusual cause of right paracardiac opacity

In case of portal hypertension, mediastinal veins can be varicose, and they might be interpreted on chest radiography or scanning as mediastinal or pulmonary masses. When no portal hypertension is present, the obstruction of the inferior vena cava might cause the presence of a dilated azygos-hemiazygos system or, more rarely, a left varicose pericardiophrenic vein. We report the first case of varix of the right pericardiophrenic vein without portal hypertension explored by means of videoassisted thoracoscopy because it was misinterpreted as a pleuropericardial cyst.

CT-maximum intensity projection is a clinically useful modality for the detection of gastric varices

To evaluate the efficacy of CT-maximum intensity projection (CT-MIP) in the detection of gastric varices and their inflowing and outflowing vessels in patients with gastric varices scheduled to undergo balloon-occluded retrograde transvenous obliteration (B-RTO). Sixteen patients with endoscopically confirmed gastric varices were included in this study. All patients were evaluated with CT-MIP using three-dimensional reconstructions, before and after B-RTO. CT-MIP clearly depicted gastric varices in 16 patients (100%), the left gastric vein in 6 (32.5%), the posterior gastric vein in 12 (75.0%), the short gastric veins in 13 (81.3%), gastrorenal shunts in 16 (100%), the hemiazygos vein (HAZV) in 4 (25.0%), the pericardiophrenic vein (PCPV) in 9 (56.3%), and the left inferior phrenic vein in 9 patients (56.3%). Although flow direction itself cannot be determined from CT-MIP, this modality provided clear images of the inflowing and the outflowing vessels. Moreover, in one patient, short gastric veins were not seen on conventional angiographic portography images of the spleen, but were clearly revealed on CT-MIP. We suggest that CT-MIP should be considered as a routine method for detecting and diagnosing collateral veins in patients with gastric varices scheduled for B-RTO. Furthermore, CT-MIP is more useful than endoscopy in verifying the early therapeutic effects of B-RTO.

Collateral pathways in thoracic central venous obstruction: three-dimensional display using direct spiral computed tomography venography.

We illustrate the spectrum of venous collateral pathways caused by the thoracic central venous obstruction with direct spiral computed tomography (CT) venography and 3-dimensional reconstruction images. Venous structures that can be demonstrated with CT venography include the jugular veins; the subclavian and brachiocephalic (innominate) veins; the internal and lateral thoracic veins; the superior and inferior venae cavae; the pericardiophrenic veins; the azygos, hemiazygos, and accessory hemiazygos veins; and the intercostal veins.

Unusual complication of peripherally inserted central venous catheter placement: the left pericardiophrenic vein.

Unusual complication of peripherally inserted central venous catheter placement: the left pericardiophrenic vein.

Multi-detector row and volume-rendered CT of the normal and accessory flow pathways of the thoracic systemic and pulmonary veins.

Multi-detector row computed tomography (CT) and volume rendering can be used as an interpretive aid to present the systemic and pulmonary venous anatomy of the thorax. Both of these venous systems are routinely imaged in clinical practice and are important in interpretation of diagnostic images in health and disease. Multi-detector row CT and three-dimensional volume rendering provide high-quality near-isotropic data (ie, the longitudinal resolution approximates the in-plane resolution). The data sets allow tailored postprocessing to produce images optimized for these vessels, which are often not fully appreciated at planar axial imaging alone. Venous structures of the thorax that can be demonstrated with multi-detector row CT and volume rendering include the jugular veins; the subclavian and brachiocephalic veins; the internal and lateral thoracic veins; the superior and inferior venae cavae; the coronary sinus, the cardiac and pericardiophrenic veins, and vein grafts; the azygos, hemiazygos, and accessory hemiazygos veins; the intercostal veins; the pulmonary veins; and other thoracic veins.

Pericardial tamponade as a delayed lethal complication of central venous catheterization

EDITOR: Central venous catheters (CVCs) are commonly used to administer fluids, medications and blood products, and monitor central venous pressure. CVCs are associated with complications occurring at the time of placement, such as pneumothorax and carotid artery puncture, as well as delayed complications such as haemothorax, pericardial tamponade and catheter-related infection [1,2]. We report one of our patients who developed delayed pericardial tamponade as a complication of CVC. A 50-year-old, 62-kg Caucasian woman with a cervical schwannoma at C2–C3 level was scheduled for a routine laminectomy and tumour removal in the sitting position. A central venous catheter was inserted before surgery commenced to monitor the central venous pressure and permit infusion of fluids and drugs. The right internal jugular vein was punctured at the third attempt by an experienced anaesthesia resident and a 16-gauge catheter inserted using the Seldinger technique (MEDCOMB, 16-gauge, triple-lumen). Blood was aspirated from the middle and proximal lumens, but not from the distal lumen. A chest radiograph was not obtained because of unavailability of a portable X-ray unit. The patient was haemodynamically stable during surgery. At the end of surgery, the patient was taken to the intensive care unit. Ten hours after surgery had been completed, the systemic arterial pressure gradually decreased from 120/80 mmHg to 80/60 mmHg. Fluid and dopamine infusions were started, but the arterial pressure was unchanged. A computed tomographic (CT) scan of the cervical spine was obtained but revealed no abnormality. The patient was taken to the operating room for exploration of the wound, but no compression on the spinal cord or blood clot was found. After 12 hours of surgery, cardiorespiratory arrest developed and the patient was successfully resuscitated. A chest radiograph was then obtained. The central catheter was noted to cross the mediastinum from the right atrium to the left side of the heart. When the catheter was injected with contrast the dye filled the pericardial space (Figure 1).Figure 1: The dye filled the pericardial space.A pericardiocentesis yielded 1 L of yellow fluid with: pH 8.0, Rivalta protein 0.5 g dL−1 (differentiates between exuda and transuda), albumin 0.1 mg dL−1, glucose, 516 mg dL−1, sodium, 186 mmol L−1, potassium, 3.4 mmol L−1, chloride, 76 mmol L−1. The patient never regained spontaneous respiration or adequate circulation, and died. Several delayed complications associated with CVCs have been reported, including cardiac tamponade [3], catheter-related infection [4], unilateral and bilateral haemothorax [5], and hydromediastinum [6]. This report describes a documented case of pericardial tamponade as a delayed complication of CVC insertion. The events leading to the development of haemothorax related to CVCs have been speculated upon in previous case reports [7,8]. Catheter malposition complicates 1% to 6% of central vein cannulations. Within the thorax, central venous catheters may also be accidentally placed in the contralateral brachiocephalic vein, the internal thoracic vein, the vertebral vein, the pericardiophrenic vein and a persistent left superior vena cava [9]. In our patient, the catheter had penetrated the myocardium and allowed the infused fluid to accumulate in the pericardial sac. The medical and nursing staff should be aware of this complication, and of the clinical signs which suggest this diagnosis. Because movements of the upper limbs, head, neck and trunk also advance the catheter, the tip must remain in the upper segment of the superior vena cava, or even in the innominate vein, above a roentgenographic plane drawn through the third rib or in the T5–6 vertebral interspace, or 2 cm below the inferior clavicular border [10]. We should have aspirated from the distal lumen of the catheter and obtained the chest radiograph after the catheterization to confirm correct placement. In conclusion, there is a mandatory requirement to aspirate through the distal lumen of the CVC after insertion and before any injections are given through it or fluids infused. This should be repeated whenever there is any doubt about the location of the tip. The use of the electrocardiogram to localize the catheter tip is less helpful from the point of view of evaluating the possibility of complications.

Blind Cannulation of the Left Pericardiophrenic Vein: An Unusual Cause of Diaphragmatic Pacing

Diaphragmatic stimulation as a complication of cardiac pacing due to right ventricular perforation of an endocardial lead or penetration of a screw-in lead along the right atrial free wall, adjacent to the right phrenic nerve, has previously been described. A case of diaphragmatic pacing due to inadvertent insertion of a temporary pacing lead into the left pericardiophrenic vein via the left internal jugular vein is presented and anatomical considerations are discussed.

Collateral pathways of the left gastric vein in portal hypertension.

Since June 1974, 347 percutaneous transhepatic portal venographic studies were performed on 246 patients with portal hypertension who had had bleeding gastroesophageal varices. Of 234 patients in whom left gastric veins (LGV) (coronary) were demonstrated, 177 (75.6%) had a single LGV and 57 (24.4%) had multiple left gastric veins (21.8% had two LGVs, 2.1% had three LGVs, and 0.5% had five LGVs). Of 193 patients undergoing selective left gastric venography, spontaneous portosystemic communications to the left renal vein were found in 55, to the inferior vena cava in two, to the inferior pulmonary veins in five, to the pericardiophrenic vein in eight, to the right inferior phrenic vein in three, and to the left intercostal veins in one. Interportal communications with the left gastric vein and varices occurred from the left portal vein in 13, from the gastroepiploic vein in one, and from a superior mesenteric vein branch in one. The predominant drainage of esophageal varices was to the azygos vein in 78 of 155 patients, to the hemiazygos vein in 13, and to multiple small unnamed veins in the mediastinum in 57. Opacified varices did not extend above the level of the azygos vein arch in 71 of 130 patients; however, 59 continued cephalad to the azygos arch and drained through more superior veins of the thorax. Knowledge of the anatomy and incidence of each of these portosystemic or interportal venous communications is important to properly treat bleeding esophageal varices by surgery or angiographic embolization.

Anomalous left pulmonary venous drainage to the inferior vena cava and through the pericardiophrenic vein to the innominate vein:Left-sided Scimitar syndrome

Anomalous left pulmonary venous drainage to the inferior vena cava and through the pericardiophrenic vein to the innominate vein:Left-sided Scimitar syndrome

Circulatory bypass of the right side of the heart: VIII. The long-term functional and morphological changes in the pulmonary circulation following cava-pulmonary artery shunt

Evidence has been presented to demonstrate that in the dog at least 80 to 85% of superior vena caval flow continues to pass through a cava-pulmonary artery shunt for 81 months postoperative. Collateral flow to the inferior vena cava does not progressively increase and is primarily through the pericardiophrenic veins, although other collateral pathways probably participate to a lesser extent. Morphological examination of the pulmonary vasculature following a cava-pulmonary artery shunt reveals evidence of diffuse and focal increase in bronchial artery supply to the lung, with evidence of perfusion of alveolar capillaries by these vessels. This increase in bronchial circulation is due to a decrease in the blood pressure and volume of pulmonary artery flow following cava-pulmonary artery anastomosis, with a functional result analogous to pulmonary stenosis. These changes were most marked where the azygos vein was left open.

Arteriovenous aneurysm of phrenic vessels simulating cardiac fistula.

A child is described with an arteriovenous communication between the left phrenic artery and the left pericardio-phrenic vein. The differential diagnosis of continuous murmurs in the chest is discussed in the light of this case. The hemodynamic consequences of arteriovenous communications and indications for their surgical treatment are briefly outlined.