Image: Digital subtraction venogram demonstrating collateral | Figure 1

JIMHICR

Journal of Investigative Medicine

Image: Digital subtraction venogram demonstrating collateral flow from the left upper extremity. The accessory hemiazygos vein (white arrow) has become a prominent collateral of the left subclavian. Flow is reversed within the left bronchial veins (black arrow), seen receiving blood from the accessory hemiazygos vein and/or left superior intercostal vein. As a result, the left bronchial venous plexus is filled with contrast (yellow-dashed arrow). This plexus drains to the pulmonary veins. This case highlights the life-threatening complications that may result from neglect of an implantable central venous catheter. Preventative measures are to promptly recognize and treat catheter-related thrombosis and to remove unneeded catheters.

Read the full case on Iatrogenic Paradoxical Stroke

More about this case

Resolved Verified literature

Why you should join Figure 1

Answers:

  1. B
  2. D

Through the right femoral vein a 5 Fr KMP catheter and stiff Glidewire were used to cross the occluded IVC (Fig 1). However on the left central access was not obtained, despite numerous attempts the left popliteal vein was not canalized due to the presence of hard thrombus. The left pedal vein was cannulated instead and a 5 Fr KMP catheter placed.
Thrombolytics were initiated with heparin drip through the right femoral vein sheath at 300 units/hr and TPA through both right and left infusion catheters at 0.5 mg/hr.
The patient returned to the OR the next day and obtaining access on the left side still proved difficult. On ultrasound, no discernible popliteal vein was seen. A small superficial venous tributary was accessed and used to find a patent segment of the superficial femoral vein under fluoroscopy (Fig 2&3).
From this access point, a 0.035 in road runner wire was advanced through a support catheter to traverse the chronic occlusion in the left common femoral vein, external iliac vein, common iliac vein, and low IVC. Next kissing balloon angioplasty was performed on the infrarenal IVC with subsequent stent placement (Fig 4). Additional stents were placed inferiorly with good inline flow from the right and left lower extremity. (Fig 5). Case courtesy of:
Student: Ben Varughese, BS
Attending(s): David Wynne, MD
Program/Dept(s): Baylor College of Medicine Department of Interventional Radiology

Reconstruction from a contrast chest CT performed for possible metastatic disease in a young teen shows a large pulmonary vein (red arrow) draining into the brachiocephalic vein (yellow arrow) from the left upper lung consistent with partial anomalous pulmonary venous return (PAPVR). The usual drainage of a pulmonary vein is directly to the left atrium. In PAPVR, the pulmonary vein drains into a systemic vein. There is frequently a coexistent atrial septal defect. #ThoracicThursday

Ultrasound image of the right lower extremity show a lack of color Doppler flow (arrow) in the right distal femoral vein. The most common causes of deep vein thrombosis in the pediatric population include central venous catheter placement, hospitalization, malignancy, congenital heart disease, thrombophilia, and certain medications such as oral contraceptives, asparaginase, and corticosteroids. #MSKMonday #MusculoskeletalMonday

Coronal CT of the chest shows an arrow-shaped thrombus (arrow) in the left subclavian vein. Risk factors for venous thrombus include indwelling venous catheters and prothrombotic states or conditions. On CT, it is important to make sure that the thrombus is a true finding and not an artifact related to mixing of non-contrast opacified blood. #ThoraxThursday #ThoracicThursday