Rationale:A persistent left superior vena cava (PLSVC) is rare, but the most common thoracic venous anomaly. We report a case of PLSVC unrecognized during left subclavian vein catheterization using real-time ultrasound-guided supraclavicular approach.Patient concerns:A 79-year-old man with history of hypertension presented with traumatic subdural hemorrhage, subarachnoid hemorrhage, and epidural hemorrhage. Before the operation, a central venous catheter (CVC) was placed into the left subclavian vein.Diagnoses:A dilated coronary sinus on echocardiogram and subsequent agitated saline test confirmed the diagnosis of PLSVC.Interventions:A CVC was placed into the left subclavian vein under real-time ultrasound guide, with supraclavicular approach. A postoperative chest X-ray revealed a left-sided paramediastinal course of the CVC; the CVC was removed under the impression of malposition.Outcomes:The CVC functioned properly.Lessons:Ultrasound is used for safe and correct placement of CVC; however, the presence of PLSVC could not be detected by ultrasonography in this case. When the chest radiograph shows the central venous catheter passing along the border of the left heart and a dilated coronary sinus detected on echocardiogram, we should have suspicion of a PLSVC.
Background:Previous studies have shown that measuring the distance from the skin to the ligamentum flavum by ultrasound preceding cervical epidural block can be beneficial in excluding false loss of resistance. However, the measurement value using ultrasound may vary depending on the degree of operator experience. Therefore, we aimed to determine the depth from skin to cervical epidural space by using lateral cervical spine X-ray, which is a more intuitive method. Methods: We enrolled 102 adult patients who were scheduled to undergo cervical epidural anesthesia for vascular bypass surgery of upper arm. After attaching a steel rod on the needle insertion site, lateral cervical spine X-ray was taken before the epidural procedure. We measured the distance from the steel rod to the midpoint of interlaminar space on the spinolaminar line. The X-ray depth was compared with needle depth. Results: Of the 102 enrolled patients, 18 patients including 13 in whom we were unable to measure X-ray depth were excluded from the analysis. In total, 84 patients were included in the analysis. Concordance correlation coefficient between the X-ray-measured depth and needle depth was 0.925. Bland-Altman analysis indicated
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