Management of an accidental superior vena caval transection during a right pneumonectomy- A case report and assessment of different management options with review of literature

Kallol Dasbaksi ,Suranjan Haldar ,Kaushik Mukherjee ,Mohammad M Hossain ,Pinaki Majumdar ,Siddharth Powah ,Plaban Mukherjee

doi:10.15761/gapm.1000112

Abstract

We present a rare case of management of accidental transection of superior vena cava (SVC) during a right sided pneumonectomy for a tuberculous destroyed lung in an eighteen year old girl. While dissecting the right pulmonary artery (RPA) in a densely adherent and grossly distorted field for a planned right pneumonectomy, the SVC got transected resulting in torrential hemorrhage and severe hypotension. The ragged ends of the SVC were clamped. Fluids and inotropes were directly transfused into the right atrium (RA) which was exposed by opening the pericardium. Soon, the mean arterial pressure (MAP) could be stabilized around 50 mm Hg which had dropped to 25 mm Hg. To protect the brain from effects of increased intra cranial venous hypertension (ICVH) due to SVC clamping, the head end of the table was elevated, injection thiopentone (1000 mg) was given directly into RA and the head was wrapped with ice bags. Since the cut ends of the SVC was far apart and ragged, we could not bring them together for an end to end anastomosis. After heparinisation, a SVC to RA veno atrial (VA) shunt using venous cannulae was made and the SVC remained clamped for 20 minutes. With the establishment of the shunt, MAP increased to 80mm Hg. Pneumonectomy was completed. Since no graft could be procured, the upper end of the SVC was anastomosed end to end with the cut end of the RPA and the lower end of SVC towards the RA was closed. Post operative recovery was uneventful and the girl is doing well 6 years after the procedure. Angiograms have shown a patent SVC to RPA anastomosis with a substantial retrograde flow through the intact azygos vein (AzV).

Highlights

Injuries to superior vena cava (SVC) though rare, have been reported [1,2,3,4] during right sided pneumonectomy, some of which needed cross clamping of SVC for their successful repair
An obstructed SVC may be clamped for vascular resection reconstruction while removing an invasive tumor like thymoma or lung carcinoma [12] without much hypotension as there is adequate return though venous collaterals which develop with these conditions
Clamping an unobstructed SVC may have to be done in unavoidable circumstances like SVC injury to control bleeding

Summary

Introduction

Injuries to superior vena cava (SVC) though rare, have been reported [1,2,3,4] during right sided pneumonectomy, some of which needed cross clamping of SVC for their successful repair. This report, an extended version of our earlier publication [11], outlines the management of accidental transection of a non obstructed SVC after clamping the cut ends, by (1) use of colloids, blood and inotropes directly into an exposed right atrium to combat hypotension, (2) intravenous thiopentone and maintenance of mild hypothermia for reducing CMRO2, and (3). There was severe hypotension, with the MAP falling to 25 mm Hg and the etCO2 was 8-9 mm Hg. Vascular clamps could be applied to the divided ends of the SVC and bleeding was controlled (Figure 2B, 2C). Recovery was uneventful and she could be discharged with oral aspirin 75 mg daily She was lost to followup but revisited our out patient department after 4 years for review of the thoracotomy scar (Figure 4) which was found to be healthy. Post operative picture of the patient showing slight puffiness of face

Findings

Discussion

Conclusion