Failing to learn from the past: Report of a patient with twice failed central venous cannulation.

Sir,

A 55-year-old male, known case of periampullary carcinoma was posted for Whipple's surgery. He had a right-sided ventricular pacing wire inserted through the right subclavian and brachiocephalic vein [Figure 1a]. In the operation theatre, the electrocardiogram, non-invasive blood pressure, SPO2, EtCO2 were connected and left-sided central venous cannulation was attempted using ultrasonography guidance under local anaesthesia. The patient had a history of unsuccessful blind left internal jugular vein (IJV) cannulation. The left IJV was chosen as the patient had right-sided ventricular pacing and we thought of putting the catheter tip at the junction of the right and left brachiocephalic veins without disturbing the right ventricular pacing wire. After puncture, a guidewire was inserted and monitored under fluoroscopy. The tip of the guidewire could not be pushed towards left brachiocephalic vein and superior vena cava (SVC), but could be seen going towards the left paracardiac region. To exclude a perforation and extraluminal migration of guidewire into the mediastinum, a contrast study using a 5F multipurpose angiographic catheter was performed with the help of a cardiologist. There was opacification of a tubular channel in the left paracardiac region draining into the left coronary sinus without opacification of the left brachiocephalic vein and SVC [Figure 1b], suggesting persistent left-sided SVC (PLSVC). A small vein communicating left SVC with right SVC [Figure 1b] was also seen. Subsequently, we abandoned the procedure and left femoral venous route was used successfully for central venous catheterisation.

Figure 1

Radiograph (a) showing right ventricular pacing (thin white arrows). Digital subtraction image (b) showing persistent left superior vena cava (thick arrow) opening into the coronary sinus (thin white arrow head) and communicating with superior vena cava through a small vein (thin white arrow)

A PLSVC is the most common variant of systemic venous drainage with reported incidence of 0.3%–0.5% in healthy individuals and 13%–45% along with coexisting cardiac anomalies.[12] Embryologically, it develops due to non-obliteration of left cardinal vein which persists as left-sided SVC. In about 90% of cases, it drains into the coronary sinus through the vein of Marshall, although in a minority of cases there are exceptional sites of drainage such as the inferior vena cava, hepatic vein and left atrium. Left atrial drainage has an almost invariable association with coexisting congenital abnormalities.[3] Most common associations include atrial septal defect, ventricular septal defect, endocardial cushion defect, tetralogy of Fallot and cor- triatriatum.[4] Clinical implications of PLSVC include:[5]

Challenges during central venous cannulation, transvenous pacing and pulmonary artery catheter insertion through the left internal jugular or subclavian vein

Cardiac conduction defects and cardiac arrhythmias, mainly atrial fibrillation, owing to involvement of atrioventricular node or bundle of His by a dilated coronary sinus

Atypical drainage into the left atrium may result in systemic air embolism during cannulation due to direct entry of air into the systemic circulation

Difficult cavopulmonary anastomosis

PLSVC is considered a relative contraindication for retrograde cardioplegia as it can lead to steal in the systemic venous circulation during retrograde cardioplegia[5]

Rarely obstruction to left ventricular inflow by enlarged dilated coronary sinus.

The most common cause of difficult IJV cannulation is IJV thrombosis caused by prolonged catheterisation, malignancy, thrombophillia, local infection and spontaneous occlusion. Unicuspid valve in IJV and PLSVC may also be causes for difficult cannulation. The learning point from this case is that if there is a history of difficult left IJV cannulation, cross-sectional imaging may be helpful to exclude PLSVC and other causes of difficulty, including IJV thrombosis, which can further avoid the important clinical sequel.

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