PICC for Saturday, September 28th, 2024

Contributed by Cincinnati Childrens Hospital Medical Center
Neil Johnson MD, and Darcy Doellman RN.

History

Newborn with Omphalocele. Peripherally Inserted Central Line (PICC) requested by clinical service. Clinical notes on the PICC Placement order stated "Left SVC identified on cardiac ultrasound yesterday".

Images (Click any image to enlarge)

Question

What is the name of the venous structure outlined by the contrast injection? (Blue arrows)

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Correct answer

Aberrant Retro-aortic Left Brachiocephalic Vein

Discussion

On initial PICC placement, the PICC was identified to the left of the midline and this would be consistent with the clinical / cardiac echo diagnosis of "Left SVC".

However, upon contrast injection, it is clear that the PICC is in a left sided venous structure which does not take the usual course of a persistent Left Superior Vena Cava (SVC).

A Left SVC passes more inferiorly.  A Left SVC usually drains into the coronary  sinus (the large vein draining the heart muscle at the back of the left atrium) which then enters the right atrium as an enlarged coronary sinus,  (See image of a left SVC included below)
In this case, the venous structure crosses from left to right at a level more superior to the position of the coronary sinus and has a vertical impression on the vein at the site of the descending aorta.  This vein anastomoses with a RIGHT sided Superior Vena Cava, not the coronary sinus and is therefore a "retro-aortic left brachiocephalic vein"  - (Obsolete terminology:  " left innominate vein")
This is a rare venous anomaly but one that is well described and usually associated with other cardiac or abdominal organ abnormalities - in this case, the patient had an Omphalocele

Additional images

References

  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840759/
  • http://stopivharm.org This site contains information on PICC and PIV safety issues, including the Cincinnati standards for PICC and PIV placements
  • http://stopivharm.org/images/20201028_Upper_PICC_Line_Poster.pdf
  • http://stopivharm.org/images/20200224_Lower_Limb_PICC_Target_Position.pdf
  • http://stopivharm.org/images/Preventing_PIV_Extravasation_Injuries.ppt
  • https://embryology.ch/en/organogenesis/cardiovascular-system/development-of-the-veins/
  • https://embryology.ch/en/ This is the very BEST embryology free online teaching system from Switzerland, See the vascular organogenesis section for venous development
  • https://www.google.com/search?q=left+svc+embryology