P i c t u r e 1 . T h e r a d i o g r a p h y o f t h e a b d o me n s h o we d b l u r r i n g t h e s h a d o w o f t h e r i g h t p s o a s mu s c l e a n d k i d n e y . P i c t u r e 2 . Co mp u t e d t o mo g r a p h y o f t h e a b d o me n d e mo n s t r a t e d a l a r g e f a t t y c o n t a i n ma
A 73-year-old man had a history of rectal adenocarcinoma, receiving concurrent chemoradiation therapy and surgery 2 years ago. He was admitted for bilateral hydroureteronephrosis with obstruction level at middle third of the ureter caused by abdominal tumor. He underwent an endoscopic implant of bilateral double-J ureteral stents. Unfortunately, left ureteral perforation occurred during operation. Septic shock developed after 2 hours. The resuscitation followed by the percutaneous nephrostomy drainage was done. We inserted the central venous catheter into the left internal jugular vein to monitor central venous pressure. The placement was uneventful. A chest X-ray ( Fig. 1) showed previously placed Port-A catheter in the right subclavian vein and right superior vena cava (white arrowhead) and an aberrant central venous line via the left internal jugular vein downward along a left paramediastinal pathway (black arrowhead). The blood gas sample was obtained from the central venous catheter to reveal nonarterial bold gas analysis and the pressure wave form confirmed the catheter in the central venous system. The diagnosis of persistent left superior vena cava (PLSVC) was diagnosed. A computer tomography scan of the chest or venography to confirm presence of the catheter in the PLSVC was not performed because of the patient's unstable critical condition. The patient recovered after aggressive resuscitation and infection control.The presence of superior vena cava is the congenital venous anomaly with result of persistence of the left anterior cardinal vein during development. It is present in 0.3% of healthy individuals and 4.5% of patients with other congenital heart disease. 1 The most common PLSVC variation or vena cava is bilateral superior vena cava, like our patient. The anomaly is often detected during the left side implant of central catheter such as central venous line, pulmonary artery catheter, permanent hemodialysis catheter, and pacemaker leads. It is important for clinicians to consider the existence of PLSVC and to distinguish it from an arterial or extravascular placement, although chest radiograph shows an aberrant central catheter in an unexpected left-mediastinal course. 2 REFERENCES 1. Buirski G, Jordan SC, Joffe HS, Wilde P. Superior vena caval abnormalities: their occurrence rate, associated cardiac abnormalities and angiographic classification in a paediatric population with congenital heart disease. Clin Radiol. 1986;37:131-138. 2. Ghadiali N, Teo LM, Sheah K. Bedside confirmation of a persistent left superior vena cava based on aberrantly positioned central venous catheter on chest radiograph.Figure 1. Chest X-ray film showing previous placed Port-A catheter in the right subclavian vein and right superior vena cava (white arrowhead) and an aberrant central venous line via the left internal jugular vein downward along a left paramediastinal pathway (black arrowhead).
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