Interactive Cardiovascular and Thoracic Surgery 2:692-693(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Successful thrombectomy of the superior vena cava thrombosis in a newborn after cardiopulmonary bypass surgery
S. Dittricha,*,
C. Schlensakb and
D. Kececioglua
a Department of Congenital Heart Disease/Pediatric Cardiology, Albert-Ludwigs-University of Freiburg, Mathildenstraße 1, D-79106Freiburg, Germany
b Department of Cardiovascular Surgery, Albert-Ludwigs-University of Freiburg, Mathildenstraße 1, D-79106Freiburg, Germany
* Corresponding author. Tel.: +49-761-270-4323; fax: +49-761-270-4468
dittrich{at}kikli.ukl.uni-freiburg.de
Received June 5, 2003;
received in revised form August 26, 2003;
accepted August 27, 2003
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Abstract
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Superior vena cava (SVC)-thrombosis in a neonate after cardiac surgery is difficult to manage. This article reports on the successful treatment of SVC-syndrome in a critically ill newborn by surgical thrombectomy and reinsertion of the SVC in the right atrial appendage in the beating heart.
Key Words: Superior vena cava thrombosis; Neonate; Congenital heart disease
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1. Introduction
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Symptomatic venous thrombosis is a well-known complication of central venous catheterization in critically ill neonates [1]. The clinical characteristics of acute superior vena cava (SVC) syndrome and venous congestion can include intracerebral hemorrhage, low cardiac output, capillary leakage, and chylous hydrothorax. Various therapeutic options, including percutaneous management and systemic or local lysis, are not well-suited for application in newborns after cardiopulmonary bypass surgery [2,3].
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2. Case report
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A 3900-g male newborn presented suffering from pulmonary dysplasia with severe stenosis and regurgitation, coarctation, persistent arterial duct, and atrial septal defect. At the age of 11 days, extended end-to end anastomosis of the aorta after resection of PDA and coarctation was performed under hypothermic circulatory arrest with selective perfusion of the right carotid artery. The atrial septum defect was closed directly, dysplastic pulmonary valve resected, and the right ventricular outflow tract reconstructed by a monocusp-patch. Cardiopulmonary bypass circulation lasted 147 min. Prior to surgery, a 4-Fr catheter was inserted into the right jugular vein under anesthetic. The primary postoperative course was uneventful. Twenty-four hours after surgery the boy developed SVC syndrome with complete occlusion of the innominate vein. Venous congestion in his body's upper half and severe hemodynamic repercussion necessitated emergency thoracotomy to stabilize circulatory function. The jugular vein catheter was removed and the thrombosis visualized by simultaneous injection of contrast medium in peripheral veins in the left hand and right half of the head (Fig. 1). The boy received heparin to achieve a PTT between 45 and 65 s. After clinical stabilization 24 h later, without further hemodynamic repercussion, the superior vena cava was cut at the confluence, thrombectomy was carried out with a 3-Fr Fogarty-catheter, and the SVC reinserted into the right atrial appendage (Fig. 2), which was clamped on the beating heart. The neonate recovered rapidly from the operation. No further thrombotic events occurred during 6 months’ follow-up under subcutaneous low-molecular-weight heparin therapy.
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Fig. 1 The thrombus completely occludes the innominate vein (black arrows, innominate v.). The contrast medium was simultaneously applied in two peripheral veins in the left hand and right half of the head. Blood from the left subclavian vein (subcl. v.) drained retrogradally via the left jugular vein (jug. v.) and into a paravertebral vein meshwork.
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Fig. 2 After thrombectomy, the superior vena cava (SVC) was reinserted into the right atrial appendage (RA append.).
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3. Comment
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Our newborn patient presented acute SVC syndrome as a rare but typical complication of cardiopulmonary bypass surgery. The occurrence of deep-vein thrombosis in pediatric patients is related to the risk factors of young age, small vessel size, alterations in blood flow, and mechanical injury to the vascular endothelium during the first 4 days following catheter insertion [4]. Moreover, a procoagulative state may be triggered by the preceding extracorporal circulation [5]. In our case, acute SVC syndrome caused the dramatic deterioration in hemodynamic stability requiring resternotomy after a previously uneventful clinical course. Though pathophysiologically clear, the problem is difficult to manage. Cardiac surgery within 10 days is commonly considered a major contraindication to thrombolytic therapy [5]. On the other hand, Pilloud and colleagues recently reported two older infants after cardiopulmonary bypass surgery, in whom thrombotic SVC syndrome was solved by local low-dose urokinase treatment within 3 days [2], and Gerling et al. reported successful percutaneous aspiration in combination with local lysis 8 days after cardiac surgery in a neonate [3]. However, in our opinion, opening the chest 24 h after cardiac surgery bars systemic medical lysis, and this report represents, to the best of our knowledge, the first successful SVC thrombectomy in a neonate shortly after cardiopulmonary bypass surgery. As the SVC was already occluded and the right atrial appendage could be easily clamped for anastomosis on the beating heart, the procedure could be performed in the ICU without any further hemodynamic repercussion. Thus, we maintain that surgical thrombectomy is a promising treatment in superior vena cava syndrome in critically ill neonates with contraindications for lysis therapy after cardiopulmonary bypass surgery.
doi:10.1016/S1569-9293(03)00209-3
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References
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- Salonvaara M, Riikonen P, Kekomaki R. Clinically symptomatic central nervous catheter-related deep venous thrombosis in newborns. Acta Paediatr. 1999;88:642–646[Medline]
- Pilloud J, Rimensberger PC, Humbert J, Berner M, Beghetti M. Successful local low-dose urokinase treatment of acquired thrombosis early after cardiothoracic surgery. Pediatr Crit Care Med. 2002;3(4):355–357[Medline]
- Gerling S, Klinge J, Singer H, Hofbeck M. Successful treatment of superior vena cava thrombosis in a neonate. Eur J Pediatr. 2002;161:466–467[Medline]
- Beck C, Dubois J, Grigno A, Lacroix J, David M. Incidence and risk factors of catheter-related deep vein thrombosis in a pediatric intensive care unit: a prospective study. J Pediatr. 1998;133(2):237–241[CrossRef][Medline]
- Hunt BJ, Parrat RN, Segal HC, Sheikh S, Kallis P, Yacoub M. Activation of coagulation and fibrinolysis during cardiothoracic operations. Ann Thorac Surg. 1998;65(3):712–718[Abstract/Free Full Text]
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Abstract
1. Introduction