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Anatomical variant found during catheter insertion


[...] following nontherapeutic visceral angiography, the TLC was injected with radiocontrast for digital subtraction angiography (DSA). Clinically, a marked left jugular venous pulsation may be present on physical examination.1 Plain radiographs may demonstrate a widened mediastinum with a shadow or soft tissue density between the aortic arch and the middle third of the clavicle.1 As a result, PLSVCs are often misdiagnosed as catheter placement in the subclavian artery or the mediastinal, pericardial, or pleural space.1 The correct diagnosis is often made only after TLC or pulmonary artery catheter (PAC) placement.

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									DxImaging0909.qxp         8/25/09       9:40 AM       Page 60

                             Diagnostic Imaging Review
      G I N A LU C K I A N O W, PA- C ; D E B O R A H C O L E , PA- C , M M S c ; L E W I S J . K A P L A N , M D, FA C S , F C C M , F C C P

                                                                                                                  The patient was urgently taken to inter-
                                                                                                                  ventional radiology (IR) for visceral
                                                                                                                  angiography and possible embolization.
                                                                                                                  While she was in IR, radiologic review
                                                                                                                  of the radiograph noted that the tip of
                                                                                                                  the left subclavian TLC resided to the
                                                                                                                  left of the mediastinum and that the
                                                                                                                  TLC was pulsing in time with the car-
                                                                                                                  diac cycle. These observations raised
                                                                                                                  two possibilities: arterial, not venous
                                                                                                                  insertion, or a persistent left-sided supe-
                                                                                                                  rior vena cava (PLSVC). Accordingly,
                                                                                                                  following nontherapeutic visceral an-
                                                                                                                  giography, the TLC was injected with
                                                                                                                  radiocontrast for digital subtraction an-
                                                                                                                  giography (DSA). The DSA confirmed
                                                                                                                  venous insertion of the TLC via the
                                                                                                                  subclavian vein into a PLSVC that
                                                                                             FIGURE 1             drained into the right atrium.
                                                                                        Left subclavian              Origin of an anomaly A PLSVC is
                                                                                 triple-lumen catheter            the most common vascular anomaly in
                                                                                                                  the thorax and is identified in approxi-
                                                                                                                  mately 0.3% to 0.5% of the general
                                                                                                                  population.1 A higher incidence is
                                                                                                                  noted in 3% to 5% of patients with con-
      Anatomical variant found                                                                                    genital heart disease, principally those
                                                                                                                  with septal defects.2,3

      during catheter insertion                                                                                      A PLSVC stems from the failure of
                                                                                                                  the left cardinal vein to degenerate. In
                                                                                                                  the embryonic venous system, paired
                                                                                                                  anterior cardinal veins drain blood from
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