Beware of a Duplicate Superior Vena Cava

First Author(s)

• LW

  Logan Warren, DO

  DO
  TTUHSC Department of Surgery
  Lubbock, Texas, United States

  Disclosure information not submitted.

Research Presenters(s)

• 

  Christina Zhu, BA, BS

  Texas Tech University Health Sciences Center School of Medicine

  Disclosure information not submitted.

  Slides

Co-Author(s)

• 

  Ariel Santos, MD, MPH, FCCM

  MD, MPH, FACS, FRCSC, FCCM
  Texas Tech University Health Science Center
  Lubbock, Texas

  Disclosure information not submitted.

Title: Beware of a Duplicate Superior Vena Cava

Case Report Body:

Introduction: Duplicate superior vena cava (SVC) with persistent left SVC (PLSVC) is present in 0.3% of the population. While rare and mostly asymptomatic in patients without underlying cardiac problems, clinicians should be aware of this anomaly during central line placement as it could have serious adverse sequelae. We present a case of incidentally discovered duplicate SVC with PLSVC during placement of a central venous catheter (CVC) that led to atrial fibrillation and sudden death.

Description: A 76-year-old male with known end stage renal disease on peritoneal dialysis (PD) presented to the emergency room for abdominal pain. He was diagnosed with generalized peritonitis secondary to descending colon perforation. He underwent left hemicolectomy and removal of the infected PD catheter. On postoperative day 17, his temporary right internal jugular hemodialysis catheter ceased to function. New hemodialysis catheter was placed in his left internal jugular vein (IJV) under fluoroscopy at the interventional radiology suite as he had catheters in his right IJV and subclavian. During placement, the wire did not traverse the midline, and venogram with contrast showed a duplicate SVC draining into the coronary sinus. The catheter was inserted into the proximal left SVC and verified with fluoroscopy. One hour after placement, the patient went into atrial fibrillation with rapid ventricular rate which progressed to pulseless electrical activity without return of spontaneous circulation. A code blue was called, but the patient eventually expired.

Discussion: Duplication of SVC with PLSVC is rare in the healthy population with incidence as high as 10-11% in patients with congenital heart disease. PLSVC may cause technical difficulties with mistaken catheter manipulation into other vessels but more severely can initiate atrial fibrillation due to aberrant conduction with the atria. Incidental discovery of duplicated SVC during central vein placement or cardiac imaging is common. Additional caution in surgery and CVC placement and awareness of PLSVC leading to arrythmia is necessary if noted to be present. In this case, the line should have been removed on recognition of PLSVC and an alternative access pursued.