A 57-year-old Caucasian woman was recently diagnosed with advanced stage ovarian cancer. Otherwise healthy, she had initially consulted her general practitioner simply for abdominal distension. Further investigations [abdominal computed tomography (CT), serum CA125determination and laparoscopy] revealed a peritoneal carcinomatosis. The diagnosis of stage III (FIGO classification) ovarian cancer was established and the patient received a carboplatin-paclitaxel based chemotherapy regimen in a neoadjuvant setting. The indication of a debulking surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) was retained by our institutional tumor board. A CVL was inserted via the right jugular vein into the superior vena cava in prevision of surgery and the appropriate positioning of the catheter was verified by chest x-ray. An implantable central venous catheter (Port-a-Cath) was already in place (Fig. ).\nThe first 48 postoperative hours were marked by difficult pain management, hypotension, and transient hyperlactatemia responding to fluid replacement and norepinephrine. On postoperative day 3, she presented acute onset dyspnea when transferred from the bed to a chair, and a major drop in pulse oxygen saturation (from SpO2 96% to 83%) justified the administration of oxygen (5 L/min) via a nasal cannula. On physical examination, her body temperature was 37.4 °C, blood pressure 135/81 mmHg, heart rate 122 beats/min, respiratory rate 20/min. No chest pain was reported. Pulmonary examination revealed a bilateral reduction of basal breath sounds with dullness at percussion. Chest x-ray examination (Fig. ) showed bilateral pleural effusions that could largely explain patient’s dyspnea and oxygen desaturation. After switching from a nasal cannula to a nonrebreather mask (FiO2 0.40), the patient’s condition seemed to stabilize in supine position. A measurement of the arteriovenous oxygen difference was obtained via sampling through the arterial and central venous line after the patient was again lying in supine position (Table ).\nA sampling error or a wrong positioning of the recent CVL was suspected, but a sample taken from the Port-a-Cath confirmed the venous value. A transthoracic echocardiography (TTE) with bubble test failed to show a right-to-left shunt, atrial septum was intact. No pulmonary hypertension was detected and right ventricle was not dilated. A CT pulmonary angiography (Fig. ) showed large bilateral pleural effusions with atelectasis of both lower lobes, acute pulmonary embolism in the right middle and upper lobe pulmonary arteries, and ultimately an anatomical variant of the left upper pulmonary vein draining into the left innominate vein. Following bilateral chest drainage, the patient was treated with low molecular weight heparin twice daily. There was no evidence for deep venous thrombosis. This was followed by a significant clinical improvement, a disappearance of the platypnea–orthodeoxia complaints and a reduction of oxygen requirement over the following days.\nAt 1-year follow-up, TTE showed no right ventricular dilation and absence of pulmonary hypertension. From an oncological perspective, stability was also observed during her niraparib maintenance therapy, with absence of new lesions at a 1-year follow-up abdominal CT.
A 56-year-old woman with a medical history of multiple sclerosis, quadriplegia, sacral decubitus ulcer, chronic osteomyelitis, chronic deep vein thrombosis (DVT), chronic steroids use, and chronic Foley catheter use presented to the emergency department with severe sepsis due to multiple potential sources including urinary tract infection, soft tissue infection, or osteomyelitis. Vital signs were significant for blood pressure of 85/59 mmHg, heart rate of 63 beats per minute, respiratory rate of 33 breaths per minute, and oxygen saturation of 83% on room air. At the beginning, patient declined intubation so she was placed on 100% oxygen via nonrebreather mask. Arterial blood gas (ABG) on 100% oxygen was 7.29/49/55. Initial chest X-ray (CXR) showed small bilateral pleural effusions with suspected left lower lobe infiltrate. Despite intravenous (IV) fluid resuscitation, broad spectrum IV antibiotics, and stress dose steroids, patient became more hypotensive and IV norepinephrine was started through a right femoral CVL that was placed in the emergency department. Patient was started on heparin drip for suspected pulmonary embolism that was stopped later due to large bleeding from femoral line site and consideration of pneumonia as the cause of hypoxemia. Patient agreed later to be intubated and decision was made to remove femoral line and place a 7.0 Fr triple-lumen CVL through the left internal jugular vein (IJ) over a guidewire and under full ultrasound (U/S) guidance, which was placed easily with no complications. A CXR was obtained to confirm placement which showed that the catheter tip did not cross the midline; instead, it was extending towards the left of the aortic arch probably into an anomalous vein as read by the radiologists (). Ultrasound examination of the neck showed proper catheter placement in the left IJ. A pressure transducer was connected which showed a venous wave form with a pressure of 10 mmHg. ABG obtained from the catheter on continuous mechanical ventilation (FiO2 = 50%, positive end expiratory pressure = 5 CM H2O) showed PaO2 of 102 mmHg compared to 79 mmHg from radial arterial site. A transthoracic echocardiography, which was done to evaluate cardiac function, did not show evidence of atrial septal defect or any other cardiac malformation. Fluoroscopy study was used to place a left peripherally inserted central catheter (PICC) and to confirm the location of the left IJ CVL which demonstrated contrast injection in an anomalous pulmonary vein (). We concluded that the patient has partial anomalous pulmonary venous return (PAPVR) and the left IJ CVL was removed. The PICC line was used instead for central access.