Ann Thorac Surg 2002;73:1638-1640
© 2002 The Society of Thoracic Surgeons
Case report
Pleural flap for treating perigraft leak after a modified blalock-taussig shunt
Baran Sevket Ugurlu, MD*a,
Osman Nejat Sariosmanoglu, MDa,
Sadik Kivanc Metin, MDa,
Eyup Hazan, MDa,
Oztekin Oto, MDa
a Department of Thoracic and Cardiovascular Surgery, Dokuz Eylul University Medical School, Izmir, Turkey
Accepted for publication September 7, 2001.
* Address reprint requests to Dr Ugurlu, Dokuz Eylul Universitesi Tip Fakultesi, Gogus Kalp ve Damar Cerrahisi Anabilim Dali, Balcova 35340 Izmir, Turkey
e-mail: ugurlub{at}yahoo.com
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Abstract
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Plasa oozing through the graft after a modified Blalock-Taussig shunt is a troublesome complication. We encountered a massive leak following a modified Blalock-Taussig shunt in a 2
year-old-girl which required reexploration. The leak was treated by wrapping the polytetrafluoroethylene shunt with the parietal pleura flap harvested from the adjacent chest wall. The patient had an uneventful recovery. Covering of the polytetrafluoroethylene shunt with parietal pleura appears to stop plasma leak through the graft following a modified Blalock-Taussig shunt.
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Introduction
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Plasma leakage from an expanded polytetrafluoroethylene (ePTFE) graft following a modified Blalock-Taussig (MBT) shunt procedure is a troublesome complication. It may present as a large perigraft seroma, compressing the lung, or it may cause prolonged chest drainage [1]. The true incidence of this complication is unknown but it could be as high as 20%, with 2.5% of the patients requiring a reoperation [1, 2]. Most cases are managed conservatively, but some eventually may need surgical intervention. There is no consensus on the method of surgical treatment. Simple resection and aspiration of the perigraft seroma is complicated by a high rate of recurrence and infection [1]. Other treatment options are topical application of absorbable collagen hemostat, collagen fleece in fibrin glue, microfibrillar collagen, histoacryl tissue glue, or intraluminal injection of fibrin glue, aprotinin, thrombin, or calcium chloride [1–4]. These methods may prove ineffective in some cases leading to graft removal or replacement [5]. We report a case with severe perigraft seroma following an MBT procedure that was treated with a simple pleural wrap procedure.
The patient first presented at 9 months of age with severe cyanosis, and was found to have dextrocardia, single ventricle, pulmonary stenosis, hypoplastic branch pulmonary arteries, arterial malposition, and azygos continuity. A left MBT shunt with a 5-mm ePTFE (Gore-Tex [W. L. Gore & Assoc, Flagstaff, AZ]) graft was performed, and the patient was discharged on postoperative day 5. She was readmitted 2 weeks later for a recurrent left pleural effusion which was treated with tube drainage.
At 2 years of age, the patient presented with increasing cyanosis despite a patent left MBT shunt. A Fontan procedure was ruled out because of unfavorable pulmonary artery anatomy. She underwent a right MBT shunt with a 6-mm ePTFE graft (Gore-Tex). During the immediate postoperative period, she was noted to have a small radio-dense mass at the right apex which appeared stable. On postoperative day 17, she was readmitted because of gross enlargement of the mass on the chest x-ray film which later progressed to a massive right-sided pleural effusion requiring drainage and exploration (Fig 1).
A right sided thoracotomy revealed a wet, dense, gray-pink mass measuring 7 x 4 x 5 cm at the apex. Microscopic examination showed an almost totally acellular mass, made mostly of fibrin, which stained blue-black with the Weigert stain. Plasma was oozing profusely through the MBT graft underneath the mass. An additional intervention was deemed necessary because of the rate of discharge. A rectangular flap of pleura was harvested from the adjacent chest wall. It was sutured with a continuous 6-0 polypropylene suture on three sides. The base of the flap was left open with only a few interrupted sutures in place (Fig 2).
Fluid was observed accumulating under the flap which had bulged slightly. Total postoperative drainage was 140 mL, and her chest drain was removed on postoperative day 2. She was discharged with a normal chest roentgenogram on postoperative day 6 and had no signs of seroma on her last follow-up 3 months later.
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Fig 2. Pleural wrapping of the polytetrafluoroethylene graft with the adjacent parietal pleura. (RPA = right pulmonary artery; SVC = superior vena cava.)
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Comment
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Plasma leakage in this patient may be attributed to a number of factors. She had discontinued aspirin only a few days before her operation, and had received heparin during and immediately after it. In their study of MBT shunts complicated by seroma, Berger and colleagues [1] found heparin administration as the only significant risk factor with multivariate analysis. A constitutional factor may have played a role, as inhibition of fibroblast growth by sera from patients with seroma was demonstrated in one study and as our patient had a similar problem following her initial shunt procedure [6]. Graft properties affect plasma leakage profoundly as computer models of ePTFE grafts have shown greatly increased permeability with only a slight increase in mean distance between the fibers [7]. The original graft in this case was divided for use in several patients and the subsequent resterilization process may have compromised wall integrity.
Regardless of the cause, the patient had a massive leak from the graft wall, which required an additional cover to make it plasma-tight. Various biological and nonbiological materials have been used for this purpose with mixed results. The parietal pleura is a readily available autogenic material and can be harvested and implanted with ease. Its effect can be mediated through several mechanisms. The increase in the fluid pressure around the graft may alter outward hydrodynamic forces. Close association of the graft with the pleura and the chest wall may increase absorption or may provide a rapidly adhesive surface around the graft. The use of pleura carries no additional expense and does not increase the risk of infection. Although we have used this method in only one case, the effective resolution of this rather massive leak, in a short time and without a recurrence, convinced us of its merit.
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References
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Berger R.M.F., Bol-Raap G., Hop W.J.C., Bogers A.J.J.C., Hess J. Heparin as a risk factor for perigraft seroma complicating the modified Blalock-Taussig shunt. J Thorac Cardiovasc Surg 1998;116:286-293.[Abstract/Free Full Text]
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LeBlanc J., Albus R., Williams W.G., et al. Serous fluid leakage: a complication following the modified Blalock-Taussig shunt. J Thorac Cardiovasc Surg 1984;88:259-262.[Abstract]
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Maitland A., Williams W.G., Coles J.G., Freedom R.M., Trusler G.A. A method of treating serous fluid leak from a polytetrafluoroethylene Blalock-Taussig shunt. J Thorac Cardiovasc Surg 1985;90:791-793.[Abstract]
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Sim E.K.W., Wong M.L., Tan C.T.T., Lee C.N. Histoacryl tissue adhesive: an alternative means of stopping polytetrafluoroethylene graft sweating. Ann Thorac Surg 1993;106:1227-1228.
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Vince D.J., LeBlanc J.G., Culham J.A. Recurrent perigraft seroma treated by graft replacement with homograft iliac artery. Pediatr Cardiol 1989;10:113-114.[Medline]
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Ahn S.A., Machleder H.I., Gupta R., Moore W.S. Perigraft seroma: clinical, histological and serological correlates. Am J Surg 1987;154:173-178.[Medline]
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Tabata R., Kobayashi T., Mori A., et al. A computer simulation of the plasma leakage through a vascular prosthesis made of expanded polytetrafluoroethylene. J Thorac Cardiovasc Surg 1993;105:598-604.[Abstract]
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Abstract
Introduction
