Ann Thorac Surg 2004;77:715-718
© 2004 The Society of Thoracic Surgeons
Case report
Successful salvage of inferior vena cava rupture during reoperative repair for ascending aortic aneurysm
Chien-Chang Chen, MDa,
Shih-Rong Hsieh, MDa*
a Department of Surgery, Division of Cardiovascular Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
Accepted for publication April 8, 2003.
* Address reprint requests to Dr Hsieh, Section of Cardiovascular Surgery, Department of Surgery, Taichung Veterans General Hospital, 160, Section 3, Taichung-Kang Road, Taichung, Taiwan, ROC
e-mail: season{at}mail.vghtc.gov.tw
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Abstract
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A 44-year-old man underwent reoperative repair for ascending aortic aneurysm at our hospital. He had received aortic valve replacement due to severe aortic regurgitation 4 years previously. The cardiopulmonary bypass was set up through the femoral arterial and venous cannula. An unusual experience of rupture of the abdominal inferior vena cava was encountered after total-body retrograde perfusion. The tragic situation was successfully salvaged by recannulation into the intrapericardial inferior vena cava and repair of the several perforations on abdominal inferior vena cava. The patient recovered smoothly except for mild pancreatitis. The causes of rupture of the inferior vena cava are discussed here.
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Introduction
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Rupture of the abdominal inferior vena cava (IVC) during cardiopulmonary bypass can bring about a disastrous consequence if it is not detected and reversed promptly. Such a condition may theoretically happen occasionally; nevertheless, to the best of our knowledge, it has not been reported before. Recently, we encountered an unusual experience of rupture of the IVC after total-body retrograde perfusion during reoperative repair of an ascending aortic aneurysm.
A 44-year-old man who had undergone aortic valve replacement 4 years previously because of severe aortic regurgitation presented with chest discomfort and fatigue that had become worse in the past half year. Echocardiography demonstrated that the prosthetic aortic valve functioned well. Computed tomographic aortography revealed an aneurysm of the ascending aorta with a maximal diameter of 6.2 cm (Fig 1).
The anterior wall of the aneurysm was thin and just adhered to the sternum.
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Fig 1. Computed tomographic aortography revealed an aneurysm of the ascending aorta with a maximal diameter of 6.2 cm. The anterior wall of the aneurysm was very thin and adhered to the sternum.
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Before resternotomy, cardiopulmonary bypass was set up from the femoral arterial and venous cannula. The left femoral artery and vein were explored through a longitudinal skin incision over the inguinal region. The femoral artery was cannulated with a 24-F cannula (Sarns 013030; Terumo Corp, Tokyo, Japan). A purse-string suture (6-0 Prolene) was made over the greater saphenous vein near its junction with the femoral vein. A no. 16 needle was introduced into the saphenous vein. The length between the needle puncture site and the right atrium was measured. A 21-F heparin-bound multipored venous cannula (CX*EB21VLH; Terumo Corp, Tokyo, Japan) was used for femoral venous cannulation by the standard guidewire technique. The tip of the cannula was placed in the right atrium. Its position was checked by the transesophageal echocardiography. The venotomy was secured by a tourniquet over the purse-string suture. There was only one attempt during this cannulation, which was performed smoothly. The venous cannula was Y-connected to the branch of the arterial conduit (Fig 2).
After commencement of cardiopulmonary bypass (CPB), the initial venous return was inadequate and, therefore, the CPB was stopped. The cause was possibly a too small venous cannula, which was removed accordingly. We performed a second venous cannulation with a 24-F multipored cannula (FEMII024V; Edwards Lifescience, Salt Lake City, UT) by the same guidewire technique. The second cannulation was as smooth as the first time, and there was only one attempt, as well. After that, the blood flow of the CPB was perfect and could be elevated to 4,000 mL/min (2.55 mL/min/m2). During femoral cannulation, a venting catheter of the left ventricle was placed through the left ventricular apex through a left anterior thoracotomy. The circulating blood temperature was cooled to 16°C. During cooling of the systemic blood, the midline sternotomy was performed. The thin anterior aneurismal wall (about 1 mm) adhered densely on the posterior table of the sternum so that division of the two structures was impossible. The aneurysm ruptured and therefore hypothermic total circulatory arrest began. Topical cooling of the head was performed. The whole anterior aneurismal wall was opened longitudinally and a Hemashield graft, 22 mm in diameter, was chosen for replacement. The distal anastomosis was performed with a continuous 4-0 Prolene. During this period, the myocardium was protected by intermittent direct perfusion through both coronary ostia. Before completion of the distal anastomosis, total-body retrograde perfusion was commenced through the venous line for dispelling air (see Fig 2 legend). Its flow was increased gradually up to 1,000 mL/min for 3 minutes and the pressure of the superior vena cava was between 25 and 30 mm Hg. The graft was clamped and the antegrade cardiopulmonary bypass was restarted. While preparing to perform the proximal anastomosis, venous reservoir return dropped severely. Cardiopulmonary bypass flow rate was less than 700 mL/min. This situation was accompanied by progressive distention of the abdomen. Emergent laparotomy was performed. There was a huge retroperitoneal hematoma over the lower central area. The infrahepatic inferior vena cava (IVC) was expeditiously exposed all the way down to the iliac bifurcation. Severe air block appeared in the circuit of CPB that required immediate intervention. The femoral venous cannula was withdrawn and another venous line (21-F multipored cannula) was emergently set up from the intrapericardial IVC. The abdominal IVC was clamped just below the renal vein. The CPB resumed partially. There were two perforations, 2 mm in diameter, located on the right lateral surface of the IVC and another perforation of the same size on the posterior surface near the junction of the IVC and left common iliac vein. Another larger perforation about 7 mm in diameter was noted on the posterior surface of the left common iliac vein about 3 cm distal to the aforementioned junction. They were repaired individually by 6-0 Prolene. The clamp on the abdominal IVC was then released. The circulating blood was gradually rewarmed. The proximal anastomosis of the graft-to-aorta was subsequently completed by the running suture. Systemic blood was rewarmed up to 38°C and the cardiac contraction restarted uneventfully. The total arrest time was 60 minutes. The total bypass time was 280 minutes. The intraoperative blood loss was estimated to be 8,100 mL. Blood transfusion was 10,000 mL.
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Fig 2. The venous conduit was Y-connected to the arterial conduit. During antegrade cardiopulmonary bypass, point A was clamped. The blood flow went in the direction marked by the black arrows. During total-body retrograde perfusion, point A was released while points B and C were clamped. The oxygenated blood left the oxygenator and followed the direction marked by the white arrows.
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During the postoperative course, he developed mild pancreatitis, of which he recovered after conservative treatment. There was no neurologic sequela or cardiac complications. The patient was discharged on the 26th postoperative day.
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Comment
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Reoperative repair for an aneurysm of the ascending aorta remains a challenging task for a cardiovascular surgeon. Frequently, the aneurismal wall is thin and has dense adhesion to the sternum, rendering the risk of rupture during reentry. Therefore, it is advisable to set up a femoro-femoral CPB first and then initiate systemic cooling to 16°C to 18°C [1, 2]. This measure provides a ready condition for circulatory arrest and is a vital precautionary step in the event of rupture of the aneurysm. During the cooling process, the left ventricle may gradually distend, indicating that the coronary perfusion is impaired. In this case, the left ventricle was drained by a venting catheter through the apex through the anterior thoracotomy. This approach can be performed before sternotomy and is expeditious because less adhesion is encountered.
Retrograde cerebral perfusion was first reported by Lemole and associates in 1982. It provides brain protection and dispelling of air during total circulatory arrest [3]. The method was further adapted to total-body retrograde perfusion by way of either bicaval or femoral venous cannulation by Yasuura and associates [4, 5]. In our case, we used the femoral vein cannula, which was advanced up to the right atrium for setting up the CPB. This was because we anticipated the aneurysm would rupture during sternotomy. After total circulatory arrest, the myocardium was protected by intermittent direct perfusion to the coronary ostia. The main purpose of the total-body retrograde perfusion was to dispel air after completion of the distal anastomosis and before restart of the antegrade CPB.
While preparing to perform proximal anastomosis, poor venous return to the reservoir occurred. In an animal study, total-body retrograde perfusion could reduce the amount of inflow blood that took part in the extracorporeal circulation due to great venous compliance and increased systemic vascular resistance [6]. Nevertheless, the gradually distended abdomen signaled a more serious problem. After laparotomy, severe air block in the CPB circuit and huge retroperitoneal hematoma signified venous rupture. The several perforations along the left common iliac vein and the distal IVC raised the question about how it occurred. The two cannulations may increase the risk of venous injury, despite the fact that both of them were performed smoothly by the guidewire technique with only one attempt. The initial antegrade CPB had run very well for at least 30 minutes before the circulating blood was lowered to 16°C for total circulatory arrest. We consider that there could be minor injuries of the left common iliac vein and IVC that were amplified after the retrograde perfusion, which gave rise to a high venous pressure. The evidence is that the poor venous reservoir return and progressive abdominal distention occurred minutes after completion of the total-body retrograde perfusion and restart of the antegrade CPB. During retrograde perfusion with blood flow of 1,000 mL/min, pressure of the superior vena cava increased to 25 to 30 mm Hg. This pressure is similar to previous reports [4–9]. Most papers did not mention IVC pressure except for the canine model, in which mean IVC pressure is around 25 mm Hg [9]. Under usual conditions, a venous pressure of 25 mm Hg may not cause spontaneous perforation, whereas a preexisting minor injury may become quite apparent under such venous pressure. The total arrest time was 60 minutes. It included the time spent on incision of the aneurysm, distal anastomosis, laparotomy, setup of a new IVC cannula for CPB, and cross-clamping of the infrarenal IVC. The reason why the patient could tolerate the ischemia and then survive without major complications may be due to the low systemic temperature during this period.
Previous authors reported that the advantages of the total-body retrograde perfusion are to diminish air embolism, assist in operating on aortic aneurysm without aortic clamp to reduce atheroembolism, and provide brain and abdominal visceral perfusion during hypothermic circulatory arrest [5–7]. However, we should be cautious to use this technique, especially by using femoral venous cannulation, as we have learned from this case.
This case reminds us of a potential complication associated with total-body retrograde perfusion even under standard guidewire technique in femoral cannulation. Such a condition has not been reported before. Prompt management can be life saving.
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References
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- Techniques for dissection involving the proximal aorta. In: Svensson LG, Crawford ES, eds. Cardiovascular and vascular disease of the aorta. Philadelphia: WB Saunders, 1997:316–8
- Coselli J.S., Buket S., Van Cleve G.D. Successful reoperation for ascending aorta and arch aneurysm in a Jehovah's Witness. Ann Thorac Surg 1994;58:871-873.[Abstract/Free Full Text]
- Lemole G.M., Strong M.D., Spagna P.M., et al. Improved results for dissecting aneurysms: intramural sutureless prosthesis. J Thorac Cardiovasc Surg 1982;83:249-255.[Abstract]
- Yasuura K., Ogawa Y., Okamoto H., et al. Clinical application of the total body retrograde perfusion to aortic dissection. Ann Thorac Surg 1992;53:655-658.[Abstract/Free Full Text]
- Yasuura K., Hiroshi O., Ogawa Y., et al. Resection of aortic aneurysms without aortic clamp technique with the aid of hypothermic total body retrograde perfusion. J Thorac Cardiovasc Surg 1994;107:1237-1243.[Abstract/Free Full Text]
- Shime N., Hatanaka T., Fukui M., Tojo H., Yoshioka M., Yang M. Oxygen transport and hemodynamics during retrograde whole-body perfusion. J Cardiothorac Vasc Anesth 1995;9:164-167.[Medline]
- Yasuura K, Takagi Y, Oohara, Takami Y. Total body retrograde perfusion during operations on the descending thoracic aorta. J Thorac Cardiovasc Surg 1999;118:559–61
- Matsuura A., Yasuura K., Maseki T., et al. Scand J Thorac Cardiovasc Surg 1993;27:191-193.[Medline]
- Rao P.V., Stahl R.F., Soller B.R., et al. Retrograde abdominal visceral perfusion: is it beneficial?. Ann Thorac Surg 1995;60:1704-1708.[Abstract/Free Full Text]
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Abstract
Introduction
