November 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 38-year-old non-smoking woman presented with complaints of intermittent dry cough, occasional vomiting, and dyspnea, occasionally with fever and chills. She indicated that she has suffered recurrent bouts of bronchitis and pneumonia annually over the previous 10 years. The patient had a history of upper arm localized melanoma resection 10 years earlier. She had smoked for 10 years, but quit one year prior to presentation. Her past medical and surgical histories were otherwise unremarkable.

Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (click on the correct answer to proceed to the next panel)

1. The chest radiograph shows asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows mild, bilateral, streaky central opacities, possibly reflecting airway thickening
4. The chest radiograph shows numerous small nodules
5. The chest radiograph shows volume loss involving the right thorax with a mass-like opacity projected over the right hilum

Reference as: Gotway MB. November 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(5):264-77. doi: http://dx.doi.org/10.13175/swjpcc147-14 PDF

Medical Image of the Week: Persistent Left Superior Vena Cava

Figure 1. Left subclavian central line courses in a left paramediastinal location.

Figure 2. Axial CT image of the chest shows a vessel coursing lateral to the aortic arch consistent with a persistent left superior vena cava.

A 19 year old man with acute lymphocytic leukemia was admitted to the ICU with septic shock. Due to areas of cellulitis on the right side of the chest and neck and femoral venous thrombi, a left subclavian central access was attempted. The chest x-ray obtained after line placement is shown below (Figure 1). Blood gas done from the line was consistent with venous blood and venous tranduction was seen. A CT of the chest (Figure 2) confirmed the diagnosis of persistent left superior vena cava (PLSVC).

A persistent left superior vena cava is the most common congenital thoracic venous anomaly, seen in 0.3-0.5% of the population (1). Incidence is increased in patients with congenital heart disease to 5%. In most patients a right sided SVC is also present; hence the term SVC duplication has also been used. Embryologically a PLSVC is formed when the left anterior cardinal vein is not obliterated during fetal development to form the ‘Ligament of Marshall’. It usually drains in to the coronary sinus.

Diagnosis is usually made incidentally on CT scan, echocardiography or,like in our case, after a left sided central access. Practically, its presence may complicate left sided central access including Swan Ganz Catheter placement, implantable cardioverter defibrillator (ICD) placement and during cardiac surgery including during administration of retrograde cardioplegia or cardiac transplant.

Emad Hammode MD¹, Khaled Hamed MD¹, Mohammad Hudeeb MD¹, Veronica Arteaga MD²

¹Department of Internal Medicine

²Department of Thoracic Imaging

University of Arizona Medical Canter

Tucson, AZ

Reference

1. Povoski SP, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol. 2011;9:173. [CrossRef] [PubMed]

Reference as: Hammode E, Hamed K, Hudeeb M, Arteaga V. Medical image of the week: persistent left superior vena cava. Southwest J Pulm Crit Care. 2014;9(4):242-3. doi: http://dx.doi.org/10.13175/swjpcc132-14 PDF