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eComment: Superior caval vein clamping

Bezm-i Alem Vakif Gureba Hospital, Chest Surgery Clinic, Istanbul, Turkey

Superior vena cava clamping for brachiocephalic vein cannulation during heart surgery

We read with interest the article by Erkan Kuralay in which a practical catheter insertion technique has been described for the situations of accidental loss of central venous catheters during cardiac surgery procedures [1]. The technique seems effective and promising. However, we believe there are certain points to be discussed about the author's method.

Central venous cannulation is an indispensable component of cardiac surgery. A multi-purpose catheter is inserted before initiation of the procedure and used during and after surgery. However, sometimes the catheter is lost due to various reasons (removal of the central venous line accidentally, pinch-off phenomenon, etc. [1]) during operation or it may not be easy to puncture a central vein. The latter is more frequent for pediatric cases. Clamping of the superior caval vein may not be a big issue in terms of cardiac hemodynamics during adult cardiac surgery as it conveys 1/3 of the whole body venous return to the heart [2]. Literature includes reports of complete resection or reconstruction of the superior caval vein with the use of clamps especially during surgeries of intrathoracic malignancies [3, 4] that usually last longer than a few minutes. Clamping of the superior caval vein may be safely tolerated by older children or adults; however, since the superior caval vein transports at least half of the whole body volume to the heart during the neonatal period, clamping of the superior caval vein for the insertion of catheters during cardiac operations of pediatric cases may not be hemodynamically easily tolerated. Moreover, such maneuver may lead to cardiac failure and inotropic agents may be required [2, 5]. It would be very helpful if the author could provide his experience with the technique in pediatric patients undergoing cardiac surgery.

The other issue that can be discussed is about the vein chosen for insertion of the catheter after clamping. Usually, only the head and neck regions of the body are left uncovered during cardiac surgery and the remaining body is covered with sterile dressings. Undressing the clavicular region may endanger the surgical field which is extremely dangerous when the mediastinum is exposed. Thus, extreme care should be taken to prevent contamination if a subclavian catheter is desired.

Once again, we congratulate the author about the proposed technique. We believe it would be more informative if the above issues are clarified.

	References

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1. Kuralay E. Superior vena cava clamping for brachiocephalic vein cannulation during heart surgery. Interact CardioVasc Thorac Surg 2009;9:343–344.[Abstract/Free Full Text]
2. Ugurlucan M, Basaran M, Alpagut U, Tireli E. Bidirectional inferior vena cava-pulmonary artery shunt: can it be an alternative for older patients presenting single ventricle heart disease in the third world countries? Arch Med Sci 2008;4:1–6.
3. Picquet J, Blin V, Dussaussoy C, Jousset Y, Papon X, Enon B. Surgical reconstruction of the superior vena cava system: indications and results. Surgery 2009;145:93–99.[CrossRef][Medline]
4. Rossella C, Nazari S. Superior vena cava resection without blood flow interruption. J Thorac Cardiovasc Surg 2007;134:1097–1098.[Free Full Text]
5. Tireli E, Basaran M, Kafali E, Harmandar B, Camci E, Dayioglu E, Onursal E. Peri-operative comparison of different transient external shunt techniques in bidirectional cavo-pulmonary shunt. Eur J Cardiothorac Surg 2003;23:518–524.[Abstract/Free Full Text]

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