Persistent left superior vena cava: What an anesthesiologist
Published in the Journal of Anaesthesiology Clinical Pharmacology, the authors describe a case of a 16-year-old boy admitted for anterograde dilatation of esophagus following trachea-esophageal fistula (TEF) repair presenting with severe dysphagia.

Central venous access was required for poor peripheral venous access. After induction of general anesthesia, left internal jugular vein was canulated with a 7.5-Fr triple lumen catheter under ultrasound guidance for parenteral nutrition as the right internal jugular vein (IJV) was found to be thrombosed in Doppler imaging. The procedure was uneventful.

A postoperative chest X-ray showed the catheter following a left para-mediastinal course. A paired blood sample was obtained from the most distal port of the triple lumen catheter, and peripheral vein and blood gas analysis of these samples found that both sample had identical PO2.

Previous hospital records showed that the child had undergone a total correction of tetralogy of Fallot and operative notes mentioned the presence of a PLSVC opening into the coronary sinus along with a normally draining RSVC.

The embryological drainage of the heart is different from that of the adult heart. The cardinal system that drains the embryo heart undergoes partial resorption on the left side to form the Ligament of Marshall. If this remains patent, it forms the PLSVC and drains into the right atrium via the coronary sinus.

If the right cardinal vein develops normally, the patient has a double SVC, which is the more common case. If the vein undergoes resorption (meaning, an absent right SVC), the right side venous blood drains via a brachiocephalic vein into the left SVC that ends in the left atrium either directly or through an unroofed coronary sinus in around 10% of the cases. This forms a right to left shunt.

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