Interact CardioVasc Thorac Surg 2007;6:517-518. doi:10.1510/icvts.2007.155432
© 2007 European Association of Cardio-Thoracic Surgery
Negative results - Cardiac general |
Management of superior vena cava obstruction syndrome due to thrombosis of a Contegra conduit used to re-establish the innominate vein-to-right atrium continuity
Gang Xu*,
Christos Alexiou,
Magdi Tofeig and
Tomasz J. Spyt
Departments of Cardiac Surgery and Paediatric Cardiology, Glenfield Hospital, University Hospitals of Leicester, Groby Rd, Leicester LE3 9QP, UK
Received 4 March 2007;
received in revised form 17 April 2007;
accepted 18 April 2007
*Corresponding author. Tel./fax: +44-116-2871471.
E-mail address: Gangzoom{at}yahoo.co.uk (G. Xu).
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Abstract
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Following intraoperative superior vena cava injury, venous drainage of the head, neck and upper extremities can be re-established with bovine jugular vein (Contegra) conduits. Inadequate anticoagulation, however, may lead to conduit thrombosis and superior vena cava obstruction syndrome. This can be successfully treated with percutaneous dilatation and stenting of the failed conduit.
Key Words: Contegra conduit; Superior vena cava obstruction syndrome; Innominate vein damage
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1. Introduction
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Though rare, damage to the innominate veins during cardiac surgery is a serious complication. If repair of the innominate veins is not possible, venous drainage of the upper body can be restored by reconstruction of the innominate veins using a variety of materials. Polytetrafluoro ethylene is the most commonly used material in grafts, however, other materials such as bovine jugular vein conduits (Contegra) offer superior suturing properties. The importance of adequate anticoagulation immediately post procedure is well recognised, but there is no clear guidelines regarding the issue of long-term anticoagulation. Superior vena cava obstruction syndrome can develop as a result of conduit thrombosis. This can be successfully managed by precutaneous dilatation and stenting of the conduit.
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2. Case presentation
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A 77-year-old woman with a history of mixed rheumatic valve disease undergoing mitral and aortic valve replacement, suffered irreparable damage to the confluence of the innominate veins just above the superior vena cava (SVC). Two separate Contegra conduits (bovine jugular vein tissue) 10 mm and 12 mm in diameter were used to re-establish venous drainage from the upper body to the right atrium (RA). One conduit connected the right innominate vein to the RA with the other conduit linking the left innominate vein to the RA. The reconstruction was carried out during a brief period of circulatory arrest. The patient made a full recovery and was discharged home anticoagulated with warfarin (target INR levels 2–3). Three months after the operation warfarin therapy was switched to aspirin. Unfortunately, within a month the patient presented to her GP with symptoms and signs typical of SVC obstruction syndrome. Contrast CT thorax and subsequent angiogram demonstrated a narrowing in the Contegra conduit connecting the right innominate vein and RA (Fig. 1) and occlusion of the left-sided conduit with well-developed collaterals. A decision was made to treat the patient with percutaneous angioplasty and stenting. During the procedure, a pressure gradient of 15 mmHg was measured across the narrowing. A Palmez stent 40x14 mm was placed in the right Contegra conduit and expanded to 6 atms (Fig. 2). Doppler ultrasound confirmed satisfactory relief of the obstruction with laminar flow through the stent and the conduit. Within 24 h, the signs of the SVC syndrome had resolved and the patient was discharged home on warfarin. Three months later the patient has remained symptom free.
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Fig. 2. (a) Angiogram showing the true extent of narrowing within the right Contegra conduit prior to stent deployment, (b) Angiogram post stent deployment.
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3. Discussion
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The innominate vein damage during cardiac surgery is a rare but serious complication, which can be managed in several ways. Patch repair using autologous tissue or polytetrafluoroethylene (PTFE) can be useful, but it was not appropriate in this case. When repair is not possible, venous drainage of the upper body can be restored by forming a direct connection between the innominate veins and the RA. This can be achieved using various materials, the most common being PTFE grafts, autologous spiral vein grafts and autologous pericardial tissue. Spiral vein grafts have been reported to offer superior long-term outcome compared to PTFE conduits [1], but take a significant amount of time to prepare and require saphenous vein harvesting. We elected to use bovine jugular vein tissue (Contegra conduit) to create two separate connections from each innominate vein to the RA. Contegra conduits have excellent suturing properties when compared to PTFE grafts and no extra theatre time is needed for vein harvesting, as is the case in spiral vein grafts. Contegra conduits are commonly used in paediatric cases [2], but its use in adults is rarely reported. We chose to restore venous drainage from both innominate veins (even though it is recognised that the left innominate vein can be ligated without serious long-term consequences [3]) because we feel that this would facilitate the early postoperative recovery and would allow time for the development of collateral circulation. Interestingly, it has been shown that separate bilateral innominate vein reconstruction or the isolated right innominate vein reconstruction offer superior long-term patency compared to the isolated left innominate vein reconstruction or the use of a Y graft, in patients with SVC reconstruction using PTFE conduits [4].
The need for anticoagulation after SVC repair is recognised. However, there is little guidance regarding the long-term use of warfarin therapy in such cases. This may be partly due to malignancy being the most common cause of SVC obstruction syndrome. The cessation of warfarin therapy in our patient is highly likely to be responsible for the development of SVC obstruction syndrome. However, we cannot explain why this particular patient suffered such catastrophic thrombosis of the Contegra conduits so soon after switching from warfarin to aspirin therapy. Given the complexities of a repeat median sternotomy in this patient, we decided to manage the conduit failure using a precutaneous intervention. Stenting in SVC syndrome due to malignancy is well described, with good short–mid-term prognosis [5]. A small retrospective study looking into the use of precutaneous stenting in patients with failed SVC conduits, showed also good long-term outcome [6].
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Acknowledgements
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Written consent was obtained from the patient for publication.
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Abstract
1. Introduction