title: Accidental insertion of a percutaneous venovenous cannula into the persistent left superior vena cava of a patient undergoing liver transplantation.
abstract: OBJECTIVE
  Persistent left superior vena cava (PLSVC) is a rare congenital vascular abnormality found in 0.3% of the general population. We report herein a rare complication involving the accidental insertion of a large bore cannula into the PLSVC during liver transplantation (LT).
  
  
  METHODS
  A 63-yr-old man with primary sclerosing cholangitis presented for LT. Given the existence of a tunnelled dialysis catheter in the right internal jugular vein (IJV) and a triple lumen catheter via the left IJV, insertion of an 18 French cannula for venovenous bypass (VVB) was performed via the left IJV using the existing triple lumen cannula as a conduit for a guidewire. Upon initiation of VVB, profound systemic hypotension occurred, and liver transplantation was completed without the further use of VVB. A chest x-ray confirmed a malposition of the VVB cannula with a large left hemothorax. A mini-sternotomy was performed for removal of the VVB cannula, which was found to be inserted in the PLSVC. Retrospectively, the presence of PLSVC was not anticipated due to a normal superior vena cava and a left innominate vein, as revealed by the course of a pre-existing left internal jugular vein triple lumen catheter on a preoperative chest x-ray, and due to a normal-sized coronary sinus on preoperative echocardiography.
  
  
  CONCLUSIONS
  Malpositioning of a venous cannula in a PLSVC should be anticipated as one of the potential complications of vascular access via the left internal jugular vein.
authors.affiliation: Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, M469.11, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
authors.forename: Kristin L
authors.initials: KL
authors.lastname: Schreiber
authors.affiliation: Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, M469.11, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
authors.forename: Takashi
authors.initials: T
authors.lastname: Matsusaki
authors.affiliation: Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, M469.11, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Bane
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Christian A
authors.initials: CA
authors.lastname: Bermudez
authors.affiliation: Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, M469.11, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
authors.forename: Ibtesam A
authors.initials: IA
authors.lastname: Hilmi
authors.affiliation: Department of Anesthesiology, The McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, M469.11, 200 Lothrop Street, Pittsburgh, PA, 15213, USA. sakait@upmc.edu.
authors.forename: Tetsuro
authors.initials: T
authors.lastname: Sakai
mesh_terms: D002405:Catheterization, Central Venous / Q000009:adverse effects*; D015209:Cholangitis, Sclerosing / Q000601:surgery; D006801:Humans; D007022:Hypotension / Q000209:etiology; D007601:Jugular Veins; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D019300:Medical Errors; D008875:Middle Aged; D014683:Vena Cava, Superior / Q000002:abnormalities*