PubMed · 5620705
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S Ia Marmorshteĭn, A Kh Trakhtenberg, I V Bidiak. [Possible errors in assessing azygograms].. https://pubmed.ncbi.nlm.nih.gov/5620705/
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The aim of this study was to determine the frequency of radiographically evident central venous catheter misplacement in the azygos arch and to analyze whether the frequency of azygos arch cannulation is dependent on the anatomical site of catheter insertion. We reviewed 1,287 postprocedural examinations and 3,441 follow-up examinations. Catheters had been inserted through the left (6%) or right (15%) internal jugular veins and through the left (32%) or right (46%) subclavin veins. Radiographs were analyzed for possible catheter malposition in the azygos arch and for complications related to this malposition. Catheter malposition in the azygos arch was seen on 16/1,287 (1.2%) postprocedural radiographic examinations. Of the 16 malpositioned catheters, 11 (69%) had been inserted in the left subclavian vein, three (19%) in the left jugular vein, two (12%) in the right subclavian vein, and none (0%) in the right jugular vein. There was a statistically significant difference in the frequency of azygos arch cannulation between left- and right-sided catheters (p = 0.001). All complications consisted of venous perforations and were seen in three of 16 cases (19%). Azygos arch cannulation is a rare but hazardous central venous catheter malposition that occurs early after catheter insertion and carries a substantial risk for complication. The risk for azygos arch cannulation is substantially increased if catheters are inserted in left-sided veins. Because of the severity of subsequent complications, radiologists should be vigilant in the detection of this rare malposition.
Left and right atrial isomerism, comprising congenital heart defects with disturbances in normal left-right asymmetry, are phenotypically distinct after birth, although animal models suggest a common embryologic origin. We postulated that the prenatal phenotype may indeed be similar in both syndromes but that differential fetal loss is responsible for the distinct postnatal phenotypes. Distinctive fetal echocardiographic features of these syndromes have not been described in detail. We therefore sought markers of left atrial isomerism that could be recognized prenatally by echocardiography and compared our results with postnatal data to identify unique intrauterine features. We reviewed 10 cases at our center and 28 published cases of cardiac malformations with atrial isomerism detected by fetal echocardiography. Postnatal imaging and autopsies provided definitive diagnoses. Ninety-five percent of cases exhibited left atrial isomerism and formed the primary study population. Echocardiographic markers included a large azygos continuation of an interrupted inferior vena cava, atrioventricular block with structural heart disease, and viscerocardiac heterotaxy. At least 1 of these markers was seen in all of our center's cases. The incidences of most cardiac lesions detected prenatally were similar to those detected postnatally. However, although the incidences of atrioventricular septal defect and pulmonary outflow obstruction in live births were 50% and 45%, respectively, they were found much more frequently among stillbirths (80% each). In summary, we identified key fetal echocardiographic features highly sensitive for left atrial isomerism. Fetal loss selects against certain lesions such as atrioventricular septal defect. The spectrum of cardiac disease suggests a greater primitivity of the fetal heart than previously shown; the typical cardiac phenotypes are closer to right atrial isomerism than are their extrauterine presentations.
An 11-mo-old girl developed cyanosis following hemi-Fontan for hypoplastic left heart syndrome. Azygos vein "steal" was diagnosed at catheterization and successfully treated by transcatheter coil embolization. Clinical improvement was seen immediately and at 5-mo follow-up.