Persistent left superior vena cava diagnosed during haemodialysis catheter placement - a case report.

The vascular access preparation for this patient was poor due to poor accessibility to surgical service, and his peripheral veins were not good for arterio-venous fistula. He was initiated on haemodialysis with a right sided internal jugular catheter (IJC). The right IJC was removed due to infection. There was previously a documented attempt to insert a left sided IJC in September 2010, however the catheter was immediately removed as post-procedure chest x-rays showed that the catheter was inside the left atrium. The procedure was repeated again the next day, and the chest x-rays showed the same finding, and the catheter was removed. He was then put on dialysis using right femoral catheter as a temporary measure, as his right internal jugular vein was not visualised on ultrasound scanning. The patient refused to switch the dialysis modality to peritoneal dialysis. We proceeded to insert a cuffed catheter in the femoral vein. He remained well on haemodialysis until May 2012, when he developed a catheter-related infection. The femoral cuffed catheter was removed, and a left IJC was attempted and inserted again. The chest x-rays (figure 1) showed the catheter was entering into the left atrium. A conventional venogram was done which was not conclusive, and a CT venogram was arranged. The CT venogram showed the catheter was in the left internal jugular vein, both left subclavian and brachiocephalic veins united to drain into the vein with the catheter in-situ which descended into the left atrium (figure 2). Another vein was seen at the junction of the left subclavian and left internal jugular crossing the midline and draining into the right superior vena cava (SVC) in keeping with the left brachiocephalic vein. The findings were suggestive of a double SVC with a persistent left SVC draining into the left atrium. Unfortunately this patient then developed pancytopaenia and infective endocarditis, and despite high dose antibiotics, he succumbed in August 2012.