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Critical Care |

A Case of Central Venous Catheter Malplacement?

Leslie Jette, MD; Ali Massoumi, MD
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Walter Reed National Military Medical Center, Bethesda, MD


Chest. 2013;144(4_MeetingAbstracts):304A. doi:10.1378/chest.1702648
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Abstract

SESSION TITLE: What's New in the ICU

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM

INTRODUCTION: An unexpected catheter location reveals a rare anomalous pulmonary venous return.

CASE PRESENTATION: A 49 year old man was admitted to the Intensive Care Unit (ICU) with symptomatic anemia. Past medical history included gastric adenocarcinoma resected three years previously. On presentation, he was afebrile, hemodynamically stable. His physical exam was notable only for palor. Laboratory evaluation was notable for a hemoglobin of 4.4 g/dL and hematocrit of 13%, a decline from his baseline hemoglobin of 9.7g/dL and hematocrit of 28.4%, obtained one month prior. Upon admission, a central venous triple lumen catheter was placed into his left internal jugular vein under direct ultrasound guidance with notation of nonpulsatile flow upon insertion. Radiograph obtained immediately after placement revealed the catheter extending from the left neck, approaching the mediastinum before extending laterally. With the unexpected catheter location, a blood gas was drawn from the line, revealing a PaO2 of 129 mm/Hg. With concerns for an arterial catheter placement, he was taken for an emergent evaluation under fluoroscopy. Under fluorscopy, a blush of contrast was seen within the left upper lobe and extending into the left brachiocephalic vein and superior vena cava with diagnosis of an anomalous return of the left superior pulmonary vein. The catheter was redirected under fluoroscopic guidance, and the patient recovered uneventfully.

DISCUSSION: During embryologic development, a single pulmonary vein develops at the posterior left atrial wall, then gains connections with veins of the developing lung buds. Eventually, this pulmonary vein and its branches become incorporated into the left atrium, with four pulmonary vein ostia being the most common final structure. There are a variety of pulmonary vein abnormalities arising from this developmental design. When a pulmonary vein drains into another vascular structure such as the superior or inferior vena cavae, azygous vein, right atrium or coronary sinus, it’s considered a partial anomalous pulmonary vein return (PAPVR). Isolated congenital anomalies have been noted in less than 1% of the overall population, and PAPVR is one of the more common of these. PAPVR most commonly occurs with the right superior pulmonary vein draining into the superior vena cava, and estimates suggest that <20% of all PAPVR drain the left lung. These anomalies are most commonly found incidentally in adults, with no clinical implications other than scenarios described above.

CONCLUSIONS: Partial anomalous pulmonary vein must be a consideration during evaluation of a central venous catheter that courses laterally.

Reference #1: Liman ST, S Topcu, A Elicora et al. Partial anomalous venous return of left superior pulmonary vein in adult. Ann Thorac Surg 2012;94:1355.

DISCLOSURE: The following authors have nothing to disclose: Leslie Jette, Ali Massoumi

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