Puspitasari Metalia, Sinorita Hemi, Bagaswoto Hendry Purnasidha, Kuswadi Iri, Prasanto Heru, Wardhani Yulia, Kurniawan Wahyu Tri
Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine, Universitas Gadjah Mada - Dr. Sardjito Hospital, Yogyakarta, Indonesia.
Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Universitas Gadjah Mada - Dr. Sardjito Hospital, Yogyakarta, Indonesia.
Int Med Case Rep J. 2020 Oct 1;13:465-469. doi: 10.2147/IMCRJ.S266858. eCollection 2020.
Central venous catheter (CVC) insertion is the most commonly performed clinical procedure when a patient initiates hemodialysis. Despite its clinical benefits, CVC insertion has several risks of complications. Thrombosis, venous stenosis, infection, arrhythmia, pneumothorax, and bleeding are among these complications. Malposition of the tip of the CVC can also occur with an incidence of up to 7%. One of several factors that could contribute to malposition is venous anatomy variation. Persistent left superior vena cava (PLSVC) is an extremely rare venous anatomical disorder but might have a significant clinical impact.
Here we report a PLSVC case that was identified in chest radiography after the insertion of a CVC catheter in a patient with end-stage renal disease (ESRD). A 40-year-old woman with a history of type 2 diabetes mellitus, hypertension, dyslipidemia, and obesity was presented in the emergency room with dyspnea for 1 week. Acute hemodialysis was required because of the ESRD and pulmonary edema. The PLSVC condition accompanied by various complications that occurred in this patient became a dilemma for the nephrologist in determining the diagnosis and proper CVC management.
PLSVC is the most common congenital abnormality of the vena cava, even though it has a very small incidence. PLSVC occurs in about 0.1-0.5% of the total population and reaches 10% in individuals with congenital heart abnormalities. Most PLSVC presents along with normal superior vena cava and drains into the right atrium, which makes it very difficult to see the clinical signs and symptoms. Almost all PLSVC conditions are found incidentally during or after invasive procedures such as CVC insertion. CVC insertion in the PLSVC condition needs proper management to minimize the risk of complications.
This case shows the importance of understanding the PLSVC condition, which, although very rare, is expected to increase the awareness of the nephrologist in making the diagnosis, determining appropriate management, and preventing complications, thereby improving patient safety.
当患者开始进行血液透析时，中心静脉导管（CVC）置入是最常实施的临床操作。尽管CVC置入有临床益处，但也存在多种并发症风险。这些并发症包括血栓形成、静脉狭窄、感染、心律失常、气胸和出血。CVC尖端位置异常也可能发生，发生率高达7%。导致位置异常的诸多因素之一是静脉解剖变异。永存左上腔静脉（PLSVC）是一种极其罕见的静脉解剖紊乱，但可能产生重大临床影响。
在此，我们报告一例在终末期肾病（ESRD）患者置入CVC导管后经胸部X线检查发现的PLSVC病例。一名40岁女性，有2型糖尿病、高血压、血脂异常和肥胖病史，因呼吸困难1周就诊于急诊室。由于ESRD和肺水肿，需要进行急性血液透析。该患者出现的伴有各种并发症的PLSVC情况，给肾病科医生在诊断和恰当的CVC管理方面带来了难题。
PLSVC是最常见的腔静脉先天性异常，尽管其发生率很低。PLSVC在总人口中的发生率约为0.1 - 0.5%，在先天性心脏异常个体中可达10%。大多数PLSVC与正常上腔静脉并存，并汇入右心房，这使得很难看到临床体征和症状。几乎所有PLSVC情况都是在诸如CVC置入等侵入性操作期间或之后偶然发现的。在PLSVC情况下进行CVC置入需要恰当管理，以将并发症风险降至最低。
本病例显示了了解PLSVC情况的重要性，尽管其非常罕见，但有望提高肾病科医生在诊断、确定恰当管理和预防并发症方面的意识，从而提高患者安全性。
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