Contributed by
CCHMC
Neil Johnson.
History
Multiple renal anomalies, lower limb PICC placed by the vascular access team. Unusual course.
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Question
What was the most likely position of the PICC Tip at initial placement
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Correct answer
Right Hepatic Vein
Discussion
A left-sided inferior vena cava (IVC) is a rare congenital vascular variant in which the IVC runs along the left side of the spine instead of the typical right-sided position. It usually results from persistence of the left supracardinal vein during embryologic development. While often asymptomatic and discovered incidentally on imaging, it has important implications for venous access and interventional procedures.
This variant becomes particularly relevant when placing lower extremity PICC lines (peripherally inserted central catheters). In standard anatomy, a catheter inserted from a femoral or lower extremity vein is expected to course through the right-sided IVC into the right atrium. However, in a left-sided IVC, the catheter may follow an unexpected path, potentially crossing over at the level of the left renal vein or continuing via atypical venous connections such as the azygous or hemiazygos system. This can lead to confusion during placement, misinterpretation of catheter position on imaging, or even malposition if the anatomy is not recognized.
In this case, the Vascular Access nurse placing the PICC - although very well trained and very experienced was confused by the catheter course and thought that the PICC might be arterial because it passed initially to the left of the spine.
IR staff are routinely available for assistance during PICC placement at our institution and IR assisted in resolution of this issue at the time of placement.
Pre-procedural imaging review, careful fluoroscopic guidance, and awareness of atypical venous trajectories can help ensure correct catheter placement and reduce complications.
Differential diagnosis
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References
- Ang WC, Doyle T, Stringer MD. Left-sided and duplicate inferior vena cava: a case series and review. Clinical Anatomy. 2013;26(8):990–1001. doi:10.1002/ca.22090. This is one of the most frequently cited papers specifically addressing left-sided IVC and duplicated IVC, with a detailed discussion of embryogenesis involving the supracardinal venous system. Bass JE, Redwine MD, Kramer LA, Huynh PT, Harris JH Jr. Spectrum of congenital anomalies of the inferior vena cava: cross-sectional imaging findings. Radiographics. 2000;20(3):639–652. doi:10.1148/radiographics.20.3.g00ma09639. A classic reference that explains the embryologic development of the IVC from the posterior cardinal, subcardinal, and supracardinal veins and correlates developmental errors with anomalies such as left-sided IVC, duplicated IVC, and interrupted IVC. (Widely regarded as the foundational review on IVC embryology.)