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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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Case 3 Left Superior Vena Cava
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Figure 3.3 Figure 3.4
Figure 3.5
Figure 3.6
Figure 3.7
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Findings
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▶ Venogram during placement of le-sided central line (Fig. 3.3) demonstrates a persistent le-sided superior
vena cava (SVC; arrow) draining into the coronary sinus (hollow arrow).
▶ Aer placement of the central line, the catheter is seen to the le of the spine within the le-sided SVC
(Fig. 3.4).
▶ Contrast enhanced CT of another patient demonstrates a le-sided SVC (Fig. 3.6, arrow) draining into the
coronary sinus (Fig. 3.5, arrow) at the posterior aspect of the right atrium. Note the absence of the right-sided
SVC in its expected location to the right of the aortic arch.
▶ Venogram from a dierent patient (Fig. 3.7) shows a catheter placed via the le internal jugular vein (arrow)
communicating with a branch of the le pulmonary vein (hollow arrow). is anomaly was also discovered at
the time of central line placement.
Teaching Points
▶ e most common anomaly of the SVC is duplication. Persistent le SVC with absence of a right SVC
is uncommon, seen in <1% of the general population and in 4%–11% of patients with congenital heart
disease.
▶ Persistent le SVC is due to failure of regression of the le anterior, common cardinal veins, and le sinus
horn.
▶ Le SVC most oen drains into an enlarged coronary sinus.
Rarely a persistent le SVC drains directly into the le atrium and as a right-to-le shunt can be a source of
paradoxical emboli.
▶ Partial anomalous pulmonary venous return occurs when a pulmonary vein communicates with the right
atrium or a systemic vein (as in Fig.3.7), resulting in a le-to-right shunt.
Management
▶ In addition to persistent le SVC, the dierential for abnormal course of a wire or catheter during line
placement should include intra-arterial placement and partial anomalous pulmonary venous return.
▶ Careful attention to prior imaging, when available, can alert the astute operator to venous anomalies.
Further Reading
Burney K, Young H, Barnard SA, McCoubrie P, Darby M. CT appearances of congenital and acquired abnormalities of the
superior vena cava. Clin Radiol. 2007:62(9):837–842.
Fares WH, Birchard KR, Yankaskas JR. Persistent le superior vena cava identied during central line placement:a case report.
Respir Med CME. 2011; 4(3):141–143.
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History
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▶ Pain on Injection of Implantable Venous Access Device
Figure 4.1
Case 4
Figure 4.2
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Case 4 Port Catheter Dislodged from Reservoir
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Figure 4.3
Figure 4.4
Figure 4.5
Findings
▶ Adouble-lumen, le-sided implantable venous access device (IVAD) is seen over the chest wall, but the
catheter (arrowheads) is discontigous from the reservoir (arrow).
▶ Asheath is seen in the right atrium placed from a right common femoral vein approach (Fig. 4.4).
Agooseneck snare (arrow) has been tightened around the fractured catheter fragment, which was then
removed through the sheath (Fig. 4.5).
▶ In a dierent patient (Fig. 4.6), a right-sided subclavian IVAD is seen, with narrowing of the catheter at the
thoracic outlet representing impending fracture.
Figure 4.6
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Teaching Points
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▶ “Pinch-o syndrome” is a complication specic to subclavian vein access. Repetitive trauma from motion
within costoclavicular space results in catheter fatigue and ultimately fracture. e costoclavicular space is
bounded anteriorly by the clavicle, subclavius muscle, and costocoroacoid ligament; posteriorly by the rst
rib and the anterior scalene muscle; and medially by the costoclavicular ligament. is complication can be
avoided by using the internal jugular vein approach.
▶ Pain with injection of a port is usually associated with either malpositon of the access (Huber) needle or
extravasation from a hole in or discontinuity of the catheter.
Management
▶ When pain on injection of an IVAD occurs, the management algorithm should include (1)reaccess to exclude
a malpositioned access needle; (2)evaluation of recent chest imaging to conrm position and continuity of the
catheter; and (3)contrast study of the port to evaluate for leak.
▶ When identied, discontiguous catheter fragments should be removed as soon as possible to avoid secondary
complications of free fragments in the heart or pulmonary arteries, including arrythmia and thrombosis.
▶ Removal may be performed from either a jugular or common femoral vein approach. In some cases, a tip-
deecting wire may be helpful to optimize positioning of the fragment for removal.
Further Reading
Mirza B, Vanek VW, Kupensky DT. Pinch-o syndrome:case report and collective review of the literature. Am Surg. 2004;
70(7):635–644.
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History
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▶ A56-Year-Old Man with End-Stage Renal Disease Presents with Preoperative Imaging Prior to Fistula
Placement
Figure 5.1
Case 5
Figure 5.2
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Case 5 Calcified Fibrin Sheath
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Figure 5.1
Figure 5.2
Figure 5.3
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Figure 5.4
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Findings
▶ Acalcied tubular structure (white arrow) is seen (Fig. 5.1) overlying the superior vena cava.
▶ On computed tomography (CT) (Fig. 5.2) this tubular structure is shown to be within the superior vena cava
(white arrow) representing a calcied brin sheath.
▶ Achest radiograph of the same patient prior to maturation of his dialysis stula conrms the presence of a
previous dialysis catheter (Fig. 5.3).
Teaching Points
▶ Fibrin sheaths are composed of brin and other coagulation factors that can cover a foreign body within hours
of placement. If there is opposition to a vein wall, this lm can further mature with addition of collagen and
smooth muscle cells eventually leading to catheter malfunction.
▶ Catheters surrounded by brin sheaths can usually be injected, but blood cannot be aspirated.
▶ Over time, brin sheaths can calcify and can be misinterpreted as a foreign body.
Management
▶ Initial management of malfunctioning catheters involves injection of a low-dose brinolytic (alteplase) into
each catheter lumen allowing a dwell time up to 90 minutes. While this can salvage up to 90% of catheters,
patency is usually short term.
▶ Catheters positioned in the superior vena cava above the cavoatrial junction are at higher risk for brin sheath
formation because close proximity to the vessel wall promotes deposition of muscle cells to the tip of the
catheter.
▶ In dialysis patients, development of a brin sheath determines the long-term catheter patency. To maintain
catheter patency, current guidelines of the American Society of Diagnostic and Interventional Nephrology
Clinical Practice Committee recommend ushing (locking) aer each use with either 1000 U/mL heparin or
4% trisodium citrate.
▶ More invasive techniques for catheter salvage include catheter stripping (Fig. 5.4; white arrow shows an
endovascular snare around the hemodialysis catheter used to disrupt the sheath) or catheter exchange with or
without balloon disruption of the brin sheath. If catheter exchange is chosen, a new venous puncture may be
considered to avoid placing the new catheter into the same brin sheath.
Further Reading
Heye S, Maleux G, Goossens GA, etal. Feasibility and safety of endovascular stripping of totally implantable venous access
devices. Cardiovasc Interv Radiol. 2012; 35:607–612.
Lu A, Smith DC. Calcied brin sheath masquerading as retained catheter. J Vasc Interv Radiol. 2013; 24:691.
Nayeemuddin M, Pherwani AD, Asquith JR. Imaging and management of complications of central venous catheters. Clin
Radiol. 2013; 68:529–544.
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Case 6
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History
▶ High Output from Chest Tube for 10 Days Following Esophagectomy for Early-Stage Carcinoma. What is the
Diagnosis and What Procedure is Being Performed?
Figure 6.1
Figure 6.2
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Case 6 Lymphangiogram and Thoracic Duct Embolization
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Figure 6.3 Figure 6.4
Figure 6.5
Figure 6.6
Figure 6.7
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