# A rare case of mal-positioning of an internal jugular central venous catheter due to an anomalous right upper pulmonary venous return

## TL;DR

A rare case of a misplaced central venous catheter is reported due to an unusual pulmonary vein anomaly in an elderly patient.

## Contribution

This case highlights an unusual anatomical variation causing unexpected catheter positioning and arterial oxygen levels.

## Key findings

- The catheter was found to wedge into an anomalous right upper pulmonary vein draining into the superior vena cava.
- The patient's arterial oxygen levels in the catheter blood gas were explained by the anomalous venous return.

## Abstract

Partial anomalous pulmonary venous return is a congenital defect where one or more pulmonary veins drain into the right atrium instead of the left. Most cases are asymptomatic and are discovered incidentally. Anomalous left upper pulmonary venous return is considered the most common type. We present a case of an 84-year-old male who presented to the hospital with altered mentation and suprapubic pain. He was found to be hypotensive and tachycardic and was diagnosed with septic shock of urinary source. He was resuscitated with fluids and antibiotics were started. He continued to be hypotensive and norepinephrine was started. A left internal jugular central venous catheter was inserted with no difficulty and a chest Xray was done for placement confirmation. Xray showed the catheter passing midline to the right hemithorax and pointing toward the right upper lung. A blood gas was drawn from the central catheter and showed pO2 of 80 mmHg. A CT scan was performed and showed the catheter coursing into the superior vena cava and pointing toward the right upper lung, wedging into the right upper pulmonary vein that is draining into the superior vena cava. This represents an anomalous right upper pulmonary venous return into the superior vena cava. This would also explain the imaging findings and the unexpected arterial levels of oxygen in the catheter blood gas. The catheter was removed and a femoral central venous access was established.