Central Venous Line Placement in a Left-Sided SVC

Abstract

Introduction Persistent left superior vena cava (PLSVC) is a rare thoracic venous anomaly due to failure of the left cardinal vein to regress during embryogenesis.1 The prevalence is estimated at 0.2–3% in the general population and 1.3–11% in those with congenital heart disease.1 In ~90% of cases, it coexists with a right superior vena cava (RSVC), creating a double SVC (DSVC).2 An isolated PLSVC occurs when the caudal portion of the RSVC regresses in utero, a variant more frequently associated with congenital heart disease (e.g., single ventricle, atrioventricular septal defect, tetralogy of Fallot) and situs abnormalities.2 The majority of PLSVCs drain into the right atrium through the coronary sinus, resulting in patients remaining asymptomatic.1 In a left atrial draining PLSVC, patients can be asymptomatic unless there is a right to left shunt present, leading to cyanosis, syncope, exercise intolerance, or progressive fatigue.2 PLSVC is clinically significant for anesthesiologists, as it can complicate central line, Swan–Ganz, or pacemaker placement from the left side, interfere with retrograde cardioplegia delivery, and predispose to arrhythmias due to coronary sinus dilation.2 Case Presentation A 34-year-old woman with IgA nephropathy and end-stage renal disease (ESRD) on hemodialysis (HD) presented for a living donor kidney transplant. Right internal jugular (IJ) central venous line (CVL) placement with ultrasound-guidance was attempted but the wire encountered resistance. Left IJ CVL was placed with ultrasound-guidance with no immediate complications. Placement was confirmed with the wire visualized in the vein in the transverse and longitudinal axis with ultrasound and pressure-tubing visual manometry drop x 2. Discussion PLSVC with a co-occurring RSVC is asymptomatic, but an isolated PLSVC can cause arrhythmias3 as the coronary sinus expands with right atrial drainage, causing compression of the AV node and His bundle.2 PLSVC can complicate the placement of Swan-Ganz catheter and pacemaker placement via a left-sided subclavian approach.3 PSLVC can also affect retrograde cannula placement into the coronary sinus, affecting cardioplegia delivery in cardiac surgery.1 Life-threatening complications have been associated with vascular manipulation of PSLVC including cardiogenic shock and coronary sinus thrombosis through acute interruption of cardiac venous drainage.1,2 Vascular anomalies like PLSVC can lead to anxiety from misinterpretation, unnecessary interventions, or procedural delays. In this patient, contrast venography confirmed the diagnosis, avoiding further risk and guiding future vascular access planning. Early identification of PLSVC is useful for facilitating central access, transvenous device placement, and retrograde cardioplegia delivery. It can also increase vigilance for the risk of potential arrhythmias during perioperative care. PLSVC may go undiagnosed due to the preference for R IJ CVL placement and lack of symptoms due to DSVC.