CTICasesSVC and IVC Occlusion with Systemic Venous Collaterals to the Left Atrium
Imaging findings
A patient with ESRD and multiple prior dialysis lines has occlusion of both the SVC and IVC. CT shows extensive chest wall varices and systemic venous collaterals draining into the left atrium via pulmonary veins, with contrast appearing in the aorta and left heart but essentially none in the pulmonary artery or right heart, indicating right-to-left shunting. The collateral-surrounded pulmonary artery sheath with non-opacified blood creates a false appearance of pulmonary embolism, and there are pleural effusions.
Key takeaways
With both cavae occluded, systemic venous return finds its way to the left atrium through collaterals that anastomose with pulmonary veins, producing a right-to-left shunt that explains hypoxemia and can mimic pulmonary embolism because contrast bypasses the pulmonary arteries. Recognizing the caval occlusions and the collateral pathways avoids repeated futile PE studies, and elevated central venous pressure contributes to effusions that cannot drain.
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