Abstract
OBJECTIVE: This work highlights the importance of recognizing persistent left superior vena cava (PLSVC), which is an uncommon venous anomaly that may complicate venous access during neuroendovascular procedures. Although rarely encountered in routine neurosurgical practice, identification of this anomaly can guide appropriate access selection and facilitate safe procedural planning. CASE PRESENTATION: An 81-year-old woman presented with tinnitus. Magnetic resonance imaging revealed a left sigmoid sinus dural arteriovenous fistula (dAVF). Cerebral angiography revealed feeders mainly from the left occipital artery and shunt points at both the distal sigmoid sinus and jugular valve. The proximal transverse sinus was occluded, and venous drainage proceeded anterogradely into the internal jugular vein (IJV). The lesion was classified as Borden type I, and transvenous embolization was selected as the treatment strategy. The left brachiocephalic vein could not be catheterized during the procedure. Angiography revealed a PLSVC without the left brachiocephalic vein, and cone-beam CT confirmed drainage into the right atrium via the coronary sinus. A guide system was successfully navigated into the left IJV through the PLSVC, and coil embolization was performed from the distal to proximal segments. Final angiography confirmed complete obliteration of the shunts, and the tinnitus resolved. CONCLUSION: Awareness of PLSVC, even for neuroendovascular surgeons with limited exposure to the thoracic venous anatomy, can aid in selecting optimal venous access routes and help avoid unexpected procedural difficulties. This case demonstrates that recognizing a PLSVC can meaningfully contribute to the success of transvenous embolization.