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Correspondence  |   February 2018
Unusual Catheter Placement on Chest Radiograph: Two Dimensions, Two Possible Locations (or More)
Author Notes
  • Stanford University School of Medicine, Stanford, California (A.K.S.S.). annaswen@stanford.edu
  • (Accepted for publication November 9, 2017.)
    (Accepted for publication November 9, 2017.)×
Article Information
Correspondence
Correspondence   |   February 2018
Unusual Catheter Placement on Chest Radiograph: Two Dimensions, Two Possible Locations (or More)
Anesthesiology 2 2018, Vol.128, 424. doi:10.1097/ALN.0000000000002013
Anesthesiology 2 2018, Vol.128, 424. doi:10.1097/ALN.0000000000002013
To the Editor:
In their recent Images in Anesthesiology report, Deshpande et al. presented a radiograph of a central venous catheter residing in a persistent left superior vena cava.1  We appreciate their discussion of the importance of recognizing and considering catheter placement in patients with this uncommon anatomical variant.
We do not, however, believe that the radiograph definitively establishes that the catheter is in a persistent left superior vena cava. In the image, the catheter courses caudad and vertically, parallel to the vertebral column. Accordingly, the catheter could be in a persistent left superior vena cava, as Deshpande et al. conclude. It could also be in a left internal thoracic vein, which also courses vertically as it passes below the clavicle in an anterior-posterior projection.2  As a catheter is advanced further, it would course toward (and even across) the midline if it resides within a persistent left superior vena cava. A catheter in an internal thoracic vein would remain more or less parallel to the vertebral column as it approaches the diaphragm, as does the catheter in the image shown. Any of several imaging studies could help clarify the presented image. A lateral radiograph would show a catheter in an internal thoracic vein as anterior and a catheter in a persistent left superior vena cava more posteriorly. A contrast study showing drainage into a dilated coronary sinus or the left atrium would confirm placement in a persistent left superior vena cava, as could a saline contrast echocardiogram or other advanced imaging study.3 
Distinguishing catheter placement between these veins is clinically important, as Deshpande et al. explain. A persistent left superior vena cava would raise suspicion of associated cardiac anomalies whereas placement in an internal thoracic vein would not. Also, a catheter in an internal thoracic vein should be not be considered “central” and may be prone to extravasation due to the smaller caliber of the vessel.
Competing Interests
The authors declare no competing interests.
Anna K. Swenson Schalkwyk, M.D., Gregory B. Hammer, M.D. Stanford University School of Medicine, Stanford, California (A.K.S.S.). annaswen@stanford.edu
References
Deshpande, R, Band, M, Kurup, V . Persistent left superior vena cava: Unusual catheter position on chest x-ray film. Anesthesiology 2017; 127:165 [Article] [PubMed]
Gibson, F, Bodenham, A . Misplaced central venous catheters: Applied anatomy and practical management. Br J Anaesth 2013; 110:333–46 [Article] [PubMed]
Ghadiali, N, Teo, LM, Sheah, K . Bedside confirmation of a persistent left superior vena cava based on aberrantly positioned central venous catheter on chest radiograph. Br J Anaesth 2006; 96:53–6 [Article] [PubMed]