Variant thoracic venous drainage and its hazards with catheter for haemodialysis

A 63-year-old man commenced haemodialysis for acuteon-chronic kidney disease following urgent coronary artery bypass grafting on a background history of type 2 diabetes mellitus and hypertension. Following initial treatment with a temporary dialysis catheter placed into the right femoral vein, a dual-lumen permanent catheter (Tesio line) was placed via the left internal jugular vein. The left internal jugular vein was punctured under ultrasound guidance and the line was inserted without any difficulty. There was a good flow in both lumens. A routine post-insertion chest radiograph was performed (Figure 1). We reasoned that the usual left-sided internal jugular line goes into the left internal jugular vein, leftsided brachiocephalic vein and then crosses the midline at the upper border of the first right costal cartilage to enter the superior vena cava (SVC) on the right-hand side of the chest radiograph. The tips should lie at the level of the atrialcaval junction and ∼4 cm beyond this into the right atrium. In this case, the line did not cross the midline and looked like a mirror image of a right-sided jugular line. A venogram was requested to confirm the line position (Figure 2). This venogram confirmed that there was a persistent left-sided SVC and the line tips were in this vessel.