What can a thrombus in the superior vena cava (SVC) do to a
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An 80-year-old lady with diabetes mellitus, hypertension and ischaemic heart disease, chronic kidney disease with a baseline serum creatinine of 300 mol/L was admitted for acute pulmonary edema secondary to acute coronary syndrome (ACS) and required noninvasive ventilatory (NIV) support. She developed acute-on-chronic kidney failure with serum creatinine rising to 500 mol/L with oliguria and further desaturation despite noninvasive ventilatory (NIV) support and echocardiography showed global hypokinesia with ejection fraction down to 30%.

She was transferred to intensive care 2 days later and underwent ultrasound-guided temporary haemodialysis catheter insertion into the right internal jugular vein (IJV) (Figure 1A). She had two CRRT sessions with net ultrafiltration of 6 L and was weaned off NIV support. She returned to the general medical ward after 3 days of ICU stay and received maintenance haemodialysis twice a week. On Day 12, change of the haemodialysis catheter over a guidewire was attempted, but there was resistance as the guidewire was advanced to 20–22 cm from the venous entry port, and the catheter was removed.

Two days later, ultrasound-guidance insertion of another haemodialysis catheter into the right IJV was attempted, but was again met with resistance after advancing 22 cm down the insertion site, and a 16 cm-long catheter was finally inserted using the Seldinger technique with smooth non-pulsatile blood aspirated from both lumens. CXR post-insertion however showed the catheter tip in the right subclavian vein (Figure 1B). Contrast CT thorax confirmed this location with no evidence of vascular injury but there was a filling defect in the superior vena cava (SVC) suggestive of a thrombus (Figure 1C), suggesting that the misdirection of the new catheter into the right subclavian vein could be the result of SVC thrombosis arising from the previous catheter. The catheter was subsequently removed and peritoneal dialysis was planned. Unfortunately, the patient developed ACS and succumbed.

Source: https://onlinelibrary.wiley.com/doi/10.1111/nep.14050?af=R
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