Ann Thorac Surg 2001;72:1382-1384
© 2001 The Society of Thoracic Surgeons
Case report
Minimally invasive removal of a dislocated stent from the right atrium after previous CABG
Thorsten Walles, CMa,
Uwe Klima, MDa,
Artur Lichtenberg, MDa,
Arjang Ruhparwar, MDa,
Kazuko Shiraga, MDa,
Axel Haverich, MDa
a Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
Accepted for publication July 27, 2000.
Address reprint requests to Dr Klima, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Konstanty Gutschowstrasse 9, 30623 Hannover, Germany
e-mail: klima{at}thg.mh-hannover.de
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Abstract
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Repeat sternotomy after previous open heart operations constitutes a serious risk factor for cardiac injury, particularly in the presence of a patent internal thoracic artery. We report a case of successful minimally invasive removal of a dislocated subclavian vein stent entangled in the tricuspid valve in a patient 5 years after coronary artery bypass surgery.
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Introduction
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Repeat sternotomy after previous open heart operations constitutes a serious risk factor for cardiac injury, particularly in the presence of a patent internal thoracic artery. Our case demonstrates another possible clinical application of a minimally invasive surgical procedure for reducing operative risk associated with repeat sternotomy in previous cardiac patients
A 69-year-old woman was referred to our department with acute tricuspid incompetence because of a dislocated vascular stent that was placed in the right subclavian vein 3 months before. She had a history of familial hypercholesterolemia and coronary heart disease. In 1991, an arteriovenous fistula was constructed in her right forearm to allow lipidapharesis. A quadruple coronary artery bypass graft (CABG) was performed in 1994 using the left internal thoracic artery (ITA) as bypass graft. Because of stenosis of the right subclavian vein of unknown origin and recurrent thrombosis, a 10-mm diameter Wallstent was implanted 3 months before presentation. Three weeks after stent implantation, the patient developed right thoracic pain and exertional dyspnea. Echocardiography and roentgenogram (Fig 1) revealed dislocation of the subclavian Wallstent to the right ventricle, approximate to the free anterior wall and entangled in the tricuspid valve; thus, causing severe tricuspid incompetence. Myocardial ischemia as the etiology for the thoracic complaints was excluded by myocardial scintigraphy. An attempt to extract the stent by right ventricular catheterization failed. The patient was placed on anticoagulant therapy, and referred to our department for stent removal by surgical procedure. The patient, in good general health, presented with exertional dyspnea and NYHA class II. A systolic tricuspid murmur without propagation was audible. No peripheral edema nor signs of pulmonary hypertension were detectable. Because of the absence of ischemia in the myocardial scintigram, repeat cardiac catheterization was not performed.
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Fig 1. Preoperative chest roentgenogram, lateral view. Top inset shows the dislocated subclavian Wallstent in the right atrium. The bottom inset shows a magnification of the stent entangled in the tricuspid valve.
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The patient was scheduled for minimally invasive removal of the dislocated stent. An anterolateral right thoracotomy 6 cm in length was performed in the fifth intercostal space. With single left lung ventilation, the pericardium was opened longitudinally over a 6-cm length above the phrenic nerve. Several sutures were used to suspend the pericardium and approximate it to the thoracotomy. After systemic heparinization, normothermic cardiopulmonary bypass was implemented by cannulation of the left femoral artery, direct cannulation of the inferior vena cava and percutaneous cannulation of the right jugular vein advanced to the superior vena cava. Both venae cavae were surrounded by polyester bands allowing total cardiopulmonary bypass. After electrical induction of ventricular fibrillation, the right atrium was opened to access the right atrioventricular valve. The Wallstent (length, 3.5 cm) was observed to be entangled between the anterior and septal tricuspid valve leaflet, and was extracted in whole without complication. Transesophageal echocardiography revealed competence of the tricuspid valve poststent removal. The atriotomy was closed with a running polypropylene suture and cardiac sinus rhythm restored by external defibrillation. The patient was weaned from extracorporeal circulation after a total bypass time of 65 minutes, and was transferred to the intensive care unit for 1 day.
Surgical revision on the second postoperative day was necessary because of subclavian venous bleeding after attempted insertion of a right-sided central venous catheter. This catheter was used to insert the guidewire that was necessary for cannulation of the right jugular vein. Obviously, on one of the attempts to advance the guidewire, the subclavian vein was perforated, but did not bleed until postoperative heparinization. The revision was performed using the same minithoracotomy incision and required only one suture to the perforation site to stop the bleeding. The further postoperative course was uneventful, and the patient was discharged on postoperative day 11.
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Comment
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Repeat sternotomy after a previous cardiac procedure may be technically challenging, and is occasionally associated with significant morbidity or mortality from risk of embolism from prior grafts, sternal dehiscence, phrenic nerve injury, excessive hemorrhage, or inadvertent cardiac injury. Reoperative median sternotomy has been noted to be of particular risk in the presence of patent internal mammary artery grafts. A frequency of mortality as high as 50% has been reported after injury to patent grafts [1].
We report a patient who underwent previous CABG who presented with patent and functional bypass grafts. An approach to the right atrium through a repeat sternotomy would have jeopardized the integrity of the bypass grafts, involving potentially high risk to the patient. Delaying or declining the repeat cardiac operation for stent removal would also have invoked risk, including right ventricular wall perforation, heart insufficiency or endocarditis. We decided to offer the patient a minimally invasive procedure using a right anterolateral thoracotomy; thus, avoiding repeat sternotomy.
Right lateral thoracotomy is a well-established procedure to access the right atrium. We modified the method, recently described by Cremer and coworkers [2], to access the right atrioventricular valve. This approach provided sufficient exposure to the right atrium, and yielded highly satisfactory postoperative cosmetic results. The potential risk of sclerotic embolization by femoral artery cannulation is acceptably low. In our series of more than 50 minimally invasive atrial septal defect (ASD) closures, we were able to repair all defects in atrial fibrillation using this approach. We, therefore, strongly recommend avoiding the additional risk associated with manipulation of the ascending aorta while inserting a ballon for endoclamping and applying cardioplegic solution [3].
Direct cannulation of the inferior vena cava and percutaneous jugular vein cannulation allowed sufficient exposure of the operative field during total cardiopulmonary bypass. Normothermic ventricular fibrillation can be electrically induced. It has not been shown to be less advantageous than cold blood cardioplegia. The duration of cardiopulmonary bypass is even reduced by ventricular fibrillation [4], and the postoperative left ventricular diastolic function is improved in fibrillated hearts [5].
Our case demonstrates another possible clinical application of a minimally invasive surgical procedure for reducing operative risk associated with repeat sternotomy in previous cardiac patients.
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References
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Steimle C.N., Bolling S.F. Outcome of reoperative valve surgery via right thoracotomy. Circulation 1996;94(Suppl II):126-128.[Abstract/Free Full Text]
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Cremer J.T., Böning A., Anssar M.B., et al. Different approaches for minimally invasive closure of atrial septal defects. Ann Thorac Surg 1999;67:1648-1652.[Abstract/Free Full Text]
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Reichenspurner H., Welz A., Gulielmos V., Boehm D., Reichart B. Port-access cardiac surgery using endovascular cardiopulmonary bypass: theory, practice, and results. J Cardiac Surg 1988;13:275-280.
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Liu Z., Valencia O., Treasure T., Murday A.J. Cold blood cardioplegia or intermittent cross-clamping in coronary artery bypass grafting. Ann Thorac Surg 1998;66:462-465.[Abstract/Free Full Text]
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Casthely P.A., Shah C., Mekhjian H., et al. Left ventricular diastolic function after coronary artery bypass: a correlative study with three different myocardial protection techniques. J Thorac Cardiovasc Surg 1997;114:254-260.[Abstract/Free Full Text]
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Abstract
Introduction
