Ann Thorac Surg 2008;85:1113-1114. doi:10.1016/j.athoracsur.2007.08.031
© 2008 The Society of Thoracic Surgeons
How To Do It
Surgical Treatment for Infected Thrombus in the Superior Vena Cava Using an Off-Pump Venoatrial Shunt
Takayuki Saito, MDa,
Miki Asano, MDa,
Norikazu Nomura, MDa,
Michiko Ishida, MDa,
Akihiro Mizuno, MDa,
Takuya Nakayama, MDa,
Yuji Okada, MDb,
Akira Mishima, MDa,*
a Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
b Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
Accepted for publication August 14, 2007.
* Address correspondence to Dr Mishima, Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya, 467–8601, Japan (Email: mishima{at}med.nagoya-cu.ac.jp).
 |
Abstract
|
|---|
We report a septic patient who had an infected thrombus that extended from the right internal jugular vein to the right atrium 1 cm below the superior venocaval junction. The thrombus was successfully removed using an off-pump shunt placed between the innominate vein and the right atrium.
|
Introduction
|
|---|
Thrombus formation is commonly observed after central venous catheter placement and may play an important role in the development of certain central venous catheter–related infections [1]. Treatment of infected thrombus includes prompt removal of the catheter, antibiotics, and anticoagulation. This conservative management may be adequate in most cases, but because of a high complication rate, a surgical approach is recommended if sepsis is refractory to this conservative treatment [2].
In this report, we describe a technique in which infected thrombus mainly located in the superior vena cava (SVC) was removed using venoatrial shunt, in which cannulae were placed in the innominate vein and the right atrium.
|
Technique
|
|---|
A 56-year-old febrile woman, who was diagnosed as having central venous catheter–related septic thrombosis (Fig 1), was referred for surgical treatment because sepsis was refractory to conservative management. The thrombus extended between the right internal jugular vein and the right atrium, 1 cm below the superior cavoatrial junction.
View larger version (88K):
[in this window]
[in a new window]
|
Fig 1. Enhanced computed tomography of the chest shows a thrombus in the superior vena cava that contained a bubble-like low-density area (white arrow).
|
|
The anterior mediastinum was exposed by a median sternotomy and the pericardium was opened. Purse-string sutures were placed on the innominate vein and the right atrium using 5-0 polypropylene suture, and systemic heparinization was instituted. Activated coagulation time was maintained at greater than 250 seconds. Two 20F venous cannulae were inserted through these sutures. The two cannulae were directly connected without interposing pump tubes (Fig 2).
View larger version (28K):
[in this window]
[in a new window]
|
Fig 2. A schematic drawing shows the venoatrial shunt. Two 20F cannulae were inserted into the innominate vein and the right atrium and were connected directly. No pump or tube was interposed.
|
|
Then, the venoatrial shunt was started. A cross clamp was placed in the right atrium, 2 cm below the superior cavoatrial junction. The right brachiocephalic, azygos, and innominate veins were all encircled and then snared (Fig 2). After confirming persistence of normal sinus rhythm, a longitudinal incision was made over the anterior wall of the SVC. The thrombus adhered to inner surface of the SVC and was resected completely. The SVC was closed directly after gentle irrigation and the right atrium was unclamped. The azygos and innominate veins were reopened and the cannulae were removed.
The right internal jugular vein was exposed through another incision placed on the neck, and declotting was done with a 6F Fogarty balloon catheter (Fig 3) while the proximal right internal jugular vein was snared.
View larger version (20K):
[in this window]
[in a new window]
|
Fig 3. The thrombus in the right jugular vein was removed through another incision in the neck, while the proximal portion of the vein was snared to avoid pulmonary emboli. A 6F Fogarty balloon catheter was used.
|
|
The patient was extubated soon after the procedure and discharged from the intensive care unit on postoperative day 2. She recovered from sepsis, and her postoperative course was uneventful. The results of three consecutive blood cultures after thrombectomy were negative.
|
Comment
|
|---|
Adequate reduction of cerebral venous pressure during cross-clamping a patent SVC is important to avoid serious complications such as cerebral edema. Several surgical methods for SVC plasty in patients with chronic SVC syndrome have been reported to include simple clamping [3], clamping with cardiopulmonary bypass (CPB) [4, 5], and clamping with a juguloatrial shunt [6]. Unlike chronic SVC syndrome, few venovenous collateral veins might provide drainage of the upper body, and prolonged intraoperative clamping of the return venous flow could result in cerebral complications.
CPB is known as a useful method to achieve adequate reduction of intracranial pressure while obstructing venous return. Our patient was young and with normal cardiac function and was thought to be well tolerable of CPB. However, we eliminated the CPB because we wished to avoid a nonspecific lung injury and because septic pulmonary microemboli had already developed on this patient.
The advantage of this technique is that it is simple, less invasive, and inexpensive. However, this technique may have some downsides. In case of serious bleeding, or in case of an unexpected fall in blood pressure, conversion to on-pump may be necessary. Unlike the on-pump method, a larger-sized venous cannula is necessary to obtain adequate venous drainage.
In conclusion, removal of infected thrombus in the SVC was performed using a venovenous innominate-atrial shunt. This technique is simple, less invasive, inexpensive, and provides uninterrupted venous return, which allows time for complete removal of the thrombus in the SVC.
|
References
|
|---|
- Lordick F, Hentrich M, Decker T. Ultrasound screening for internal jugular vein thrombosis aids the detections of central venous catheter-related infections in patients with hematooncological diseases: a prospective observational study Br J Haematol 2003;120:1073-1078.[Medline]
- Kniemeyer HW, Grabitz K, Buhl R, Wust HJ, Sandmann W. Surgical treatment of septic deep venous thrombosis Surgery 1995;118:49-53.[Medline]
- Calderon MC, Lozano VM, Jaquez A, Villasenor C. Surgical repair of superior vena cava syndrome Ann Thorac Surg 2001;71:1351-1353.[Abstract/Free Full Text]
- Shimokawa S, Yamashita T, Kinjyo T, et al. Extracorporeal venous bypass: a beneficial device in operation for superior vena cava syndrome Ann Thorac Surg 1996;62:1863-1864.[Abstract/Free Full Text]
- Calhoun TR, Wright Jr RM, Cimo PL, Pai A, Windham PA, Kitten CM. Use of cardiopulmonary bypass for thrombectomy in acute superior vena cava syndrome Tex Heart Inst J 1983;4:347-350.
- Singh S, Sherif H, Reul G. Reconstruction of the superior vena cava Tex Heart Inst J 2000;27:38-42.[Medline]
Top
Abstract
Introduction
