Lines, Tubes and Drains for Wednesday, June 3rd, 2026

Contributed by Cincinnati Children’s Hospital Medical Center
Jesus Beltran-Perez, Neil Johnson, and Alfredo Ramirez.

History

Multiple renal anomalies, lower limb PICC placed by the vascular access team. Unusual course.

Images (Click any image to enlarge)

Initial fluoroscopy image after right lower limb PICC placement
Initial contrast injection after partial PICC withdrawal

Question

What was the most likely location of the PICC tip on the initial non-contrast fluoroscopy?

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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

Line tip terminating in the right renal vein, right portal vein, ductus venousus or in the peritoneal cavity.

Additional images

Guidewire advancement of PICC to the inferior cavo-atrial junction
After placement, the PICC was partially withdrawn under IR supervision and contrast was injected, proving that the PICC was in a left-sided IVC which then communicated through the anatomic left renal vein passing to the normal right-sided intra-hepatic IVC

References

  • Kellman GM, Alpern MB, Sandler MA, Craig BM. Computed tomography of vena caval anomalies with embryologic correlation. Radiographics. 1988 May;8(3):533-56. doi: 10.1148/radiographics.8.3.3380993. PMID: 3380993. Kardum D, Bečić T, Vrsalović M, Lukšić B, Carević V, Fabijanić D. LEFT-SIDED INFERIOR VENA CAVA ASSOCIATED WITH PROXIMAL DEEP VENOUS THROMBOSIS OF THE LEFT LOWER EXTREMITY. Acta Clin Croat. 2022 Mar;61(1):145-148. doi: 10.20471/acc.2022.61.01.18. PMID: 36398088; PMCID: PMC9616038.
  • There are many good explanations of fetal venous and arterial development on the internet - specifically on YouTube This is the best explanation of the development of the venous system in our opinion: https://www.youtube.com/watch?v=AQo18Dh2tx4
  • The Swiss Universities Embryology online learning system is the best available in our opinion. This is the specific section on development of the venous system but anyone interested in embryology is encouraged to peruse the whole learning system https://embryology.ch/en/organogenesis/cardiovascular-system/development-of-the-veins/introduction.html?p=0#introduction The main site: https://embryology.ch/en/