Left superior pulmonary artery sling

A pulmonary artery sling is formed when the left pulmonary artery originates from the right pulmonary artery and encircles the distal trachea, coursing between the trachea and esophagus to reach the hilum of the left lung. Pulmonary artery slings are often associated with distal tracheal narrowing, due to either intrinsic stenosis or secondary compression by the anomaly itself. We report a very rare case in which the left superior pulmonary artery originated from the right pulmonary artery and then acted as a sling, the left inferior pulmonary artery originated from the pulmonary trunk.     

Persistent left-sided superior vena cava diagnosed after flow-directed pulmonary artery catheterization; report of a case]

We describe a case of persistent left-sided superior vena cava discovered after insertion of a pulmonary artery (PA) catheter. The diagnosis was suggested by chest X-ray after PA catheter placement and was subsequently confirmed by an echocardiograph. A 68-year-old man was admitted to our ICU because of septic shock induced by MRSA enterocolitis. In order to monitor the hemodynamic state of the patient, a PA catheter was inserted through the left subclavian vein after placement of a central venous and flexible double lumen catheters through the right internal jugular and subclavian veins, respectively. A chest X-ray showed the PA catheter passing along the left border of the heart. An echocardiograph showed the PA catheter passing through the coronary sinus into the pulmonary artery. Anesthesiologists and intensivists should be aware of the occurrence of left-sided superior vena cava in order not to mistake catheters placed in it as being in the arterial circulation or malpositioned outside of the venous circulation.     

Diagnosis of a left-sided superior vena cava during placement of a pulmonary artery catheter

We report a case of a left sided superior vena cava (SVC) that was diagnosed during placement of a pulmonary artery (PA) catheter. After entering the left internal jugular, the PA catheter passed into the left side of the heart, through the aortic valve, and into the aorta. This was an unusual cause of right-to-left shunting and persistent cyanosis in a patient who had undergone two open cardiac procedures, including repair of an atrial septal defect. Cardiac catherization and echocardiography also failed to reveal the abnormality.

The embryology and physiology of a left sided SVC is reviewed, including an historical perspective. A discussion of the variants of the syndrome is included, as is a review of aberrant placement of central venous catheters.     

Unusual course of a pulmonary artery catheter through a persistent superior vena cava]

We report the unusual course of a pulmonary artery catheter through a persistent left-sided superior vena cava. After left subclavian vein cannulation and downward left-sided paramediastinum course, the Swan-Ganz catheter enters the right pulmonary artery. Haemodynamic monitoring was consistent with the diagnosis of septic shock developed by this 56-year-old woman, after cephalic duodenopancreatectomy. Persistent left-sided superior vena cava occurs in 0.5% of the population and 5-10% of patients with congenital heart diseases. It drains into the right atrium through the coronary sinus in 92% of cases and is associated with an absent right superior vena cava in 20% of cases. The left-sided superior vena cava persists when the caudal part of the left anterior cardinal vein does not degenerate. A persistent left superior vena cava may be medically relevant during implantation of pacemaker leads or radiofrequency ablation, during cardiac surgery for placement of a retrograde coronary sinus cardioplegia catheter and during transjugular intrahepatic portosystemic shunt placement.     

Difficult placement of a pulmonary artery catheter due to a persistent left vena cava superior

The incidental detection of a persistent left vena cava superior during insertion of a pulmonary artery catheter in a patient with acute respiratory distress syndrome (ARDS) prior to extracorporeal membrane oxygenation (ECMO) therapy is reported. A persistent left vena cava superior is the most frequent thoracic malformation and can be associated with other malformations such as congenital heart disease. Therefore, further diagnostic evaluation is needed especially in pulmonary hypertension and ARDS. Anaesthesiologists should be aware of the specific aspects associated with a persistent left vena cava superior.     

Discovery of left-sided superior vena cava during central venous catheterization

We describe a 3-yr-old patient in whom a central venous catheter (CVC) was inadvertently inserted into a persistent left superior vena cava (PLSVC). This congenital anomaly was diagnosed using transthoracic echocardiography. The aetiology and the implications for the anaesthetist are discussed.      

Venous catheterization and congenital abnormalities of the superior vena cava

Persistent left superior vena cava is encountered in about 0.3 to 0.4% of human beings. It derives from remnants of the left cardinal vein system. This results in either a duplication of the superior vena cava or in a single left vena cava. The diagnosis is easy in case of associated cardiovascular anomalies. Two cases of single left vena cava and one case of duplication of the superior vena cava are described. All were identified owing to repeatedly aberrant courses of central venous catheters. Diagnosis was easily provided by angiography. Clinical course was uneventful. Despite its usual good tolerance, the persistence of a left vena cava, as an isolated anomaly, must not be neglected as it carries many practical implications which are reviewed.