Persistence pays: An interventionally challenging case in a patient with a persistent left superior vena cava
Amel Tobaa, M.D., Allegheny General Hospital, Pittsburgh, PA
Amel Tobaa, M.D.1, Mahmoud Elrakhawy, M.D.1, Kirtivardhan Vashistha, M.D.1, Adee Elhamdani, M.D.1, Matthew C. Becker, M.D.2 and Carleen Cho, M.D.3, (1)Allegheny General Hospital, Pittsburgh, PA, (2)Saint Vincent Consultants in Cardiovascular Diseases, LLC, Erie, PA, (3)Saint Vincent Heart & Vascular Institute, Erie, PA
Title
Persistence pays: An interventionally challenging case in a patient with a persistent left superior vena cava
Introduction
Persistent left superior vena cava (PLSVC) is a rare congenital vascular anomaly seen in about 0.3 % of the general population. Patients are typically asymptomatic and are often diagnosed incidentally on imaging studies or secondary to iatrogenic complications. We present a case in which PLSVC was diagnosed as an incidental finding after placement of a temporary dialysis catheter (TDC). Clinical Case
A 57-year-old man with a history of bypass surgery and recent diagnosis of COVID-19 pneumonia was admitted to the hospital for fevers and shortness of breath. He subsequently developed acute kidney injury requiring hemodialysis for which he had a left internal jugular (IJ) vein TDC placed. Chest x-ray showed the line extending to the midline, terminating just left to the aortic knob, raising concern for mispositioning. High back pressures were reported after the line was connected to the dialysis circuit. A CT chest without contrast showed the catheter terminating left of the proximal descending thoracic aortic arch, concerning for a perforation of the left IJ at the angle of innominate vein. Vascular surgery and cardiology were consulted. Patient was taken to the OR for a central venogram and potential covered stent placement over the injured segment of the brachiocephalic vein. The left femoral vein was accessed percutaneously. A glidewire advantage was advanced into the inferior vena cava, directed towards the left brachiocephalic vein and was parked in the left subclavian vein. The guidewire advanced around the TDC with ease. A 12-french sheath was advanced and placed proximal to the temporary line. Central venogram showed a patent central venous system with a persistent tract mirroring the tract of the temporary line. There was no evidence of active extravasation or pooling of contrast. A 40 mm Reliant balloon was advanced over the guidewire and positioned at the intersection of the TDC and brachiocephalic vein. Under fluoroscopic guidance, simultaneous inflation of the balloon and removal of the TDC was done. The balloon was inflated for five minutes. Subsequently, the balloon was deflated, and a Cine run demonstrated no active extravasation. The tract was still filling with contrast and draining into the right atrium. The glidewire advantage was exchanged with a V-18 guidewire and selective cannulation of the tract was performed. A LIMA catheter was placed at the ostium of the tract. Digital subtraction angiography was performed, confirming the presence of a PLSVC. Discussion
It is important for health care professionals involved in invasive procedures to have thorough thoracic vascular knowledge. Although rare, PLSVC is the most common thoracic venous anomaly. As this case demonstrates, the PLSVC was an incidental finding initially thought to be a complication. Medical advancements have allowed for the use of interventional techniques to investigate and treat potential vascular complications. Using a multidisciplinary approach between Interventional Cardiology and Vascular Surgery, an alternative, less invasive treatment option was available for this patient, who was deemed a high-risk open surgical candidate, which confirmed the diagnosis of a PLSVC.