Successful Dialysis Through a Persistent Left Superior Vena Cava

Persistent left superior vena cava (PLSVC) is a congenital venous anomaly with atypical venous drainage, often asymptomatic so found incidentally.¹ It results from failure of left anterior cardinal vein to regress during embryogenesis.² The clinical significance depends on drainage site and accompanying cardiac anomalies as it can complicate vascular procedures.³

A 38-year-old man with IgA nephropathy progressed to end-stage chronic kidney disease and presented to us with uremic symptoms. As he had not undergone arteriovenous fistula construction, hemodialysis (HD) was planned using a temporary left internal jugular vein (IJV) catheter. Left sided IJV site was chosen to preserve right IJV for latter tunneled catheter placement.

The insertion of temporary catheter was uneventful with good flow in both lumens. Chest X ray to confirm its position however showed the catheter tip followed a left para-tracheal course [Figure 1a]. Both lung volumes were intact with no pleural collections or other abnormalities noted. Clinically, the patient was vitally stable.

Close

Figure 1:

(a) The catheter tip courses para-tracheally on the left, descending along the mediastinum. It extends beyond the level of the left hilum and projects medially, overlapping the cardiac silhouette on the frontal chest radiograph (orange arrow). (b) A 3D reconstructed image with presence of catheter in the persistent left superior vena cava PLSVC (white arrow). (c) The yellow arrow highlights the catheter lying within the left PLSVC, terminating in the coronary sinus. (d) Right side SVC is seen (blue arrow). Notably, the left innominate (brachiocephalic) vein is absent. Normally, this vein bridges venous return from the left jugular and subclavian veins into the right SVC.

Export to PPT

To rule out malposition, a CT chest with contrast was obtained. This demonstrated the left jugular venous dialysis catheter lying within a PLSVC draining in to right atrium [Figures 1b and c].

Figure 1d further confirmed that the right-sided superior vena cava was normal, with absence of the left innominate vein.

Hemodialysis was initiated through this catheter without any complications. After two sessions, symptoms improved. A right-sided permanent catheter was placed two days later and remains the current access.

A catheter in a PLSVC can be safely used for hemodialysis if positioned to drain into the right atrium, but requires imaging confirmation, vigilant monitoring, and physician awareness to prevent misinterpretation and unnecessary removal of a well-functioning catheter.