Ann Thorac Surg 2009;87:1621. doi:10.1016/j.athoracsur.2008.05.006
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Severe Tracheal Compression Due to a Seroma: A Rare Cause of Respiratory Insufficiency After a Modified Blalock–Taussig Shunt
Jennifer Conway, MD, FRCPCa,*,
Wojtek Karolak, MDb,
Deborah Thompson, MD, FRCPCc,
Andrew E. Warren, MD, FRCPCa,
Stacy O'Blenes, MD, FRCSCb
a Division of Pediatric Cardiology, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
b Division of Pediatric Cardiovascular Surgery, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
c Department of Diagnostic Imaging, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
* Address correspondence to Dr Conway, IWK Children's Heart Centre, 5850/5980 University Ave, P O Box 9700, Halifax, Nova Scotia, B3K 6R8, Canada (Email: jennifer.conway{at}iwk.nshealth.ca).
Leak of serous fluid through the interstices of a polytetrafluorethylene graft placed as a systemic to pulmonary artery shunt can occasionally result in the formation of a seroma around the prosthesis. We recently encountered a patient in which a shunt seroma caused significant tracheal stenosis resulting in severe respiratory insufficiency.
This 5-month-old baby was diagnosed at birth with an unbalanced atrioventricular septal defect, transposition of the great arteries, and pulmonary stenosis that was complicated by a right-sided congenital diaphragmatic hernia. He underwent surgical repair of the congenital diaphragmatic hernia on day 2 and placement of a 3.5-mm right-sided modified Blalock–Taussig (mBT) shunt with ligation of a patent ductus arteriosus on day 15. At approximately 4 months of age the child was investigated for intermittent cyanotic episodes, including cardiac catheterization, which revealed narrowing within the shunt. Because of ongoing concerns regarding the adequacy of the vasculature of the hypoplastic right lung, we elected to revise the mBT shunt with a new 5-mm graft rather than proceed with an early bidirectional cavopulmonary shunt. On postoperative day 23, the patient developed significant respiratory distress associated with intermittent right upper lobe collapse as evidenced on chest x-ray. Echocardiography was initially performed to rule out any obvious issues with the mBT shunt, but this was inconclusive. Subsequently, a computerized tomographic scan revealed a fluid collection surrounding the shunt causing severe tracheal and right bronchial compression (Fig 1).This external compression of the airways was confirmed by bronchoscopy. Intraoperative inspection revealed a serous fluid collection surrounded by a fibrin sheath and evidence of weeping from the polytetrafluoroethylene graft (Fig 2). The fluid was evacuated surgically with immediate relief of the tracheal obstruction. A catheter was left in place postoperatively until the drainage had resolved. Laboratory studies ruled out the presence of chyle or blood confirming that the fluid was in fact serous.
Respiratory distress after placement of a mBT shunt is rare, but it has been reported in association with a perigraft seroma [1]. The mechanism leading to respiratory distress after the development of a seroma is presumed to be secondary to ipsilateral bronchial compression. However, this case clearly demonstrates the possibility of a shunt seroma causing severe tracheal compression, probably related to rightward tracheal deviation secondary to the lung hypoplasia associated with this child's congenital diaphragmatic hernia. Although it is clear that survival for children with congenital diaphragmatic hernia and heart defects is poor, there is a paucity of literature on the surgical management or postoperative complications of these patients. This case highlights one of the unique anatomical features that may complicate the surgical approach and repair of cardiac defects in a patient with a diaphragmatic hernia.
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- Demircin M, Dogan R, Ozkan M, Ozsoy M, Kuzgun E, Guvener M. Perigraft seroma complicating the modified Blalock-Taussing shunts: two consecutive instances with review of the literature Turk J Pediatr 2005;46:275-278.
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