Kristin L Schreiber1, Takashi Matsusaki1, Brian C Bane1, Christian A Bermudez2, Ibtesam A Hilmi1, Tetsuro Sakai3. 1. Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, M469.11, 200 Lothrop Street, Pittsburgh, PA, 15213, USA. 2. Department of Surgery, Division of Cardiac Surgery, The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. 3. Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, M469.11, 200 Lothrop Street, Pittsburgh, PA, 15213, USA. sakait@upmc.edu.
Abstract
PURPOSE: Persistent left superior vena cava (PLSVC) is a rare congenital vascular abnormality found in 0.3% of the general population. We report herein a rare complication involving the accidental insertion of a large bore cannula into the PLSVC during liver transplantation (LT). CLINICAL FEATURES: A 63-yr-old man with primary sclerosing cholangitis presented for LT. Given the existence of a tunnelled dialysis catheter in the right internal jugular vein (IJV) and a triple lumen catheter via the left IJV, insertion of an 18 French cannula for venovenous bypass (VVB) was performed via the left IJV using the existing triple lumen cannula as a conduit for a guidewire. Upon initiation of VVB, profound systemic hypotension occurred, and liver transplantation was completed without the further use of VVB. A chest x-ray confirmed a malposition of the VVB cannula with a large left hemothorax. A mini-sternotomy was performed for removal of the VVB cannula, which was found to be inserted in the PLSVC. Retrospectively, the presence of PLSVC was not anticipated due to a normal superior vena cava and a left innominate vein, as revealed by the course of a pre-existing left internal jugular vein triple lumen catheter on a preoperative chest x-ray, and due to a normal-sized coronary sinus on preoperative echocardiography. CONCLUSION: Malpositioning of a venous cannula in a PLSVC should be anticipated as one of the potential complications of vascular access via the left internal jugular vein.
PURPOSE: Persistent left superior vena cava (PLSVC) is a rare congenital vascular abnormality found in 0.3% of the general population. We report herein a rare complication involving the accidental insertion of a large bore cannula into the PLSVC during liver transplantation (LT). CLINICAL FEATURES: A 63-yr-old man with primary sclerosing cholangitis presented for LT. Given the existence of a tunnelled dialysis catheter in the right internal jugular vein (IJV) and a triple lumen catheter via the left IJV, insertion of an 18 French cannula for venovenous bypass (VVB) was performed via the left IJV using the existing triple lumen cannula as a conduit for a guidewire. Upon initiation of VVB, profound systemic hypotension occurred, and liver transplantation was completed without the further use of VVB. A chest x-ray confirmed a malposition of the VVB cannula with a large left hemothorax. A mini-sternotomy was performed for removal of the VVB cannula, which was found to be inserted in the PLSVC. Retrospectively, the presence of PLSVC was not anticipated due to a normal superior vena cava and a left innominate vein, as revealed by the course of a pre-existing left internal jugular vein triple lumen catheter on a preoperative chest x-ray, and due to a normal-sized coronary sinus on preoperative echocardiography. CONCLUSION: Malpositioning of a venous cannula in a PLSVC should be anticipated as one of the potential complications of vascular access via the left internal jugular vein.