Rescue Strategies for Repair of Intraoperative Thoracic Vena Caval Injury
Jahanzaib Idrees, Ahmad Zeeshan, Bruce W. Lytle, Eric E. Roselli
Cleveland Clinic Foundation, Cleveland, OH
OBJECTIVE: Complications during cardiovascular procedures can result in thoracic vena caval injury. Management of this life threatening complication is challenging. Objectives are to characterize events, describe repair techniques, and assess outcomes.
METHODS: Between 1997 and 2009, 41 patients had peri-procedural thoracic vena caval injuries. Superior vena cava(SVC) was involved in 28(68%) and inferior vena cava(IVC) in 13(32%). Mean age was 65 years. Complications occurred during 1)-pacer lead extraction or caval stenting(n=7), 2)-non-cardiac thoracic surgery(n=3) and 3)-cardiac procedures (n=31). Cardiac procedures included: Valve repair or replacement(n=20), aortic repair(n=6), heart failure operation(n=2), tumor resection(n=1), atrial septal defect closure(n=1), and pericardiectomy(n=1). Fifty-two percent were re-operations. Repair techniques included primary suture repair(n=29, 71%), pericardial patch angioplasty(n=11, 27%), and pericardial tube graft reconstruction(n=1, 2%). Cardiopulmonary bypass support was used in 88%. In 2 patients, repair required hypothermic circulatory arrest: One had a large SVC posterior wall injury and another had IVC injury at the level of diaphragm. Median follow-up was 28 months.
RESULTS: There were 6 hospital deaths(15%) related to lead extraction/caval stents in 3(43%, 3/7) and following cardiac surgery 3(10%, 3/31). Postoperative morbidity included atrial fibrillation (n=15), stroke(n=2), renal dialysis(n=6), and reoperation for bleeding(n=3). Median length of stay was 9.5 days.
CONCLUSIONS: Iatrogenic thoracic caval injuries are associated with a high risk of peri-procedural death, especially in those undergoing interventional/endovascular procedures. Rescue is achievable with judicious use of CPB and may necessitate hypothermic circulatory arrest. A heart team approach utilizing multi-disciplinary collaboration protocols should be developed for procedures at high risk for caval injury.