(1043) An Anomalous Course of Central Venous Catheter

Introduction: Chest x-ray confirmation of appropriate central venous catheter placement is a common standard of practice in the intensive care unit. The tip of CVC is expected to be in the mid to lower third of the superior vena cava. Misplacement of CVC is an infrequent but known complication of CVC placement. We describe an anomalous but safe course of CVC that raised alarm in the immediate phase after placement.

Description: 41-year-old male with history of heart failure, chronic kidney disease, and obstructive sleep apnea is admitted to the ICU with suspected cardiogenic shock. His main complaint is shortness of breath. His vitals are blood pressure 70/48, pulse 79/min, respirations 20/min. On exam, he is severely volume overloaded, in moderate respiratory distress, crackles up to mid lungs bilaterally with a displaced point of maximal impulse. CVC was placed due to increasing pressor requirement. Due to respiratory distress, CVC placement was done in 30-degree head of bed elevated position. The proceduralist confirmed placement of CVC during procedure with traditional methods including vessel pressure estimation and oxygen saturation. After securing CVC a chest x-ray was ordered. The course of the vessel was reported by radiologist as possibly through a persistent left vena cava.

Discussion: Persistent left superior vena cava (PLSVC) is rare congenital vascular connection, which is a known incidental finding. The unusual finding in CXR does raise alarm in providers unfamiliar with the entity. The CVC tip in such case terminates on the left side of the trachea, often in the coronary sinus. Our patient here had an ICD already placed in 2019. The normal course of the ICD rules out at least the dominant PLSVC. Dual SVC with a smaller PLSVC can lead to similar abnormal placement. Our patient was confirmed to not have PLSVC after review of prior CT chest. After review of CT chest, the patient was noted to have a dilated left intercostal vein due to chronic venous congestion. We decided to continue using the CVC due to the acuity of illness. The patient tolerated the ICU course in a relatively uneventful manner. Our case emphasizes the use of multiple methods to confirm venous placement of CVC and the evidence to point presence or absence of PLSVC such as presence of ICD and prior radiological studies.