(1518) Where's the Line: A Case of Central Line Placement in Anatomical Variance

Introduction: When placing a right sided internal jugular central venous catheter, confirmation of placement is traditionally obtained by observing the line travel in a downward trajectory on chest radiograph. If the line crosses the midline of the patient’s chest on imaging, it indicates incorrect placement, typically within the arterial system, warranting removal.

Description: This case is a 24-year-old male with a past medical history of polysubstance use and suicidal ideation who was found down in the woods, unresponsive and hypothermic. He was admitted to the medical intensive care unit for work-up of undifferentiated shock requiring positive pressure ventilation and vasopressor support. Following placement of a central venous catheter in the right internal jugular vein, a chest radiograph showing the right central line crossing the midline created concern for inadvertent arterial insertion. However, computed tomography angiogram was obtained on admission for, at the time, undifferentiated shock. Further review of the imaging with radiology confirmed the presence of a persistent left superior vena cava (PSLVC) and thus proper line placement. Ultimately, it was determined the patient was in a mixed cardiogenic and septic shock state; the central access via PSLVC was successfully used to administer norepinephrine and dobutamine over the course of 72 hours. His shock resolved, the line was removed without complication, and the patient ultimately made a full neurologic recovery.

Discussion: PSLVC incidence in the general population is unknown due to its largely asymptomatic nature, but it is estimated to be 0.2-3%. Though rare overall, it is the most common thoracic venous anomaly. Right atrial drainage occurs in 80-90% of PSLVC; left atrial drainage accounts for the remaining instances. Consequently, whole body distribution of medications given through a central PSLVC catheter would then be largely the same as a normal variant right sided superior vena cava. Our case demonstrates that an understanding of this variance is crucial for any vascular intervention; lack thereof may lead to further unnecessary procedures, which would increase a patient’s infection, pneumothorax, and bleeding risk.