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Ann Thorac Surg 1996;62:1197
© 1996 The Society of Thoracic Surgeons

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Case Report

Direct Right Atrial Catheter Insertion With Video-Assisted Thoracic Surgery

Departments of Cardiac and General Surgery, Fresno Community Hospital and Medical Center, Fresno, California

Accepted for publication April 23, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment

 
Chronic gastrointestinal disorders may require support with long-term total parenteral nutrition via a central venous catheter. Central venous access may be problematic because of infection or thrombosis of previous catheters. We report a case where video-assisted thoracic surgical catheter insertion directly into the right atrium provided a successful and safe method of long-term central venous access for parenteral nutrition.

	Introduction

Top Footnotes Abstract Introduction Comment

 
Chronic total parenteral nutrition via central venous access has proved lifesaving for many patients suffering from a wide range of severe gastrointestinal disorders. Indwelling catheters are prone to infection and thrombosis. The surgeon may be faced with a dilemma to provide reliable venous access for a group of patients critically dependent on long-term total parenteral nutrition. Video-assisted thoracic surgery has provided the surgeon with a less invasive modality capable of providing reliable and safe catheter insertion directly into the right atrium.

A 45-year-old woman with long-standing scleroderma and severe malnutrition had been dependent on total parenteral nutrition for all her nutritional needs for the past 3 years. Recurrent venous thrombosis had complicated seven prior central venous catheters placed through internal/external jugular veins and both groin sites.

Video-assisted thoracic surgical techniques were applied with double-lumen intubation and the patient in the left lateral decubitus position. A three-port intercostal access technique was employed. The thoracoscope was used through the seventh intercostal space in the posterior axillary line. The thoracoscopic needle driver was employed via the midaxillary line in the fifth intercostal space. An atraumatic thoracoscopic grasper was inserted via the midscapular line in the fifth intercostal space.

The superior pericardium was opened 5 cm longitudinally, anterior to the phrenic nerve, providing excellent exposure to the free wall of the right atrium. A 4-0 Prolene (Ethicon, Somerville, NJ) pursestring suture was placed in the right atrium using a video-assisted thoracic surgical needle driver. A standard needle/guidewire introducer set, via the midaxillary trocar site, was then used for the insertion of a number 9.5 Groshong catheter directly into the right atrium. The pursestring suture was tied down and a second 4-0 Prolene suture was used to fix the catheter in position to the pericardial edge. All knots were tied intracorporeally. The proximal catheter end was brought out of the chest and tunneled under the subcutaneous tissues of the anterior chest wall. Care was taken to ensure slack remained on the catheter within the chest to prevent tension during lung inflation. Blood loss was minimal. A number 32 chest tube was positioned in the apex of the right pleural cavity. A postoperative chest roentgenogram confirmed excellent positioning of the catheter within the right atrium. The patient is presently 7 months postoperative without any catheter problems.

	Comment

Top Footnotes Abstract Introduction Comment

 
Video-assisted thoracic surgery may provide a safe and reliable technique for establishing direct right atrial catheter insertion for patients whose central venous system is otherwise inaccessible.

	Footnotes

Top Footnotes Abstract Introduction Comment

 
Address reprint requests to Dr Birnbaum, 110 N Valeria, Suite 204, Fresno, CA 93701.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sheldon E. Cohen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Birnbaum, P. L. Articles by Cohen, S. E. Search for Related Content PubMed PubMed Citation Articles by Birnbaum, P. L. Articles by Cohen, S. E.