Placement of an internal jugular dialysis catheter into the superior intercostal vein.

Discussion The value of a routine radiograph following an uneventful placement of an internal jugular haemodialysis catheter has been questioned. The argument is Hypoplasia or absence of the brachiocephalic vein that unsuspected findings occur in less than 1.5% of necessitates alternate pathways whereby blood from routine chest radiographs after uneventful placement the left upper extremity and left internal jugular vein of internal jugular catheters [1]. We describe an may reach the right atrium. Possibilities include a unusual venous anomaly that was revealed by a routine persistent left sided superior vena cava which drains post-procedure chest radiograph and review the poteninto the coronary sinus, as well as several variations tial complications that may have resulted if dialysis through which blood drains via superior intercostal had been initiated. veins into the accessory hemiazygos vein and subsequently into the azygos system [2]. The left paramedian location of the catheter on the Case anteroposterior radiograph raised the possibility of placement in a remnant left-sided superior vena cava, or internal thoracic (mammary) vein which runs A 79-year-old woman with a history of chronic renal insufficiency was admitted to the hospital after suffering anteriorly [3–6 ], or superior intercostal vein which runs posteriorly [7–10] (Figure 3). Placement in the a myocardial infarction. She became progressively fluid overloaded and required ventilatory support. A 16-cm pericardiophrenic vein was possible although less likely as it usually runs laterally along the cardiac border dialysis catheter was placed in the left internal jugular vein for haemodialysis access. Non-pulsatile dark [11–14]. A lateral film would have been helpful in distinguishing these possibilities but was difficult given blood was aspirated and the haemodialysis catheter was placed without difficulty using the Seldinger techthe requirement for ventilatory support. Placement of a central venous catheter in the pericardiophrenic nique. No complications were suspected. A subsequent chest radiograph (Figure 1) revealed the tip of the vessel has resulted in pericardial tamponade [13] while placement in the internal thoracic vein has resulted in catheter projecting on the lateral aspect of the proximal descending thoracic aorta. An angiogram (Figure 2) pleural effusions, chest wall abscess, pulmonary oedema, dyspnea and chest pain [5,6 ]. Placement in was performed which showed an occluded left brachiocephalic vein. Drainage of the left internal jugular the superior intercostal/hemiazygos or azygos systems has resulted in back pain [8,15]. The angiogram conand subclavian systems was through a superior intercostal vein that communicated with an accessory hemifirmed the posterior location of the catheter and probable drainage through the superior intercostal vein to azygos vein and subsequently drained into the azygos vein. The absence of any relevant medical history the accessory hemiazygos vein and finally to the azygos system. The vertical flow of contrast was inconsistent suggested that the anomaly was most likely congenital in origin. The catheter was removed due to the concern with that followed by a persistent left-sided superior vena cava. The angiogram also confirmed an occluded brachiocephalic vein which therefore precluded realignCorrespondence and offprint requests to: Mark J. Sarnak, MD, ment of the catheter in the left brachiocephalic vein, a Division of Nephrology, New England Medical Center, Box 391, 750 Washington Street, Boston, MA 02111, USA. procedure that is often recommended [11,12,14].