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Coronary sinus thrombosis: A central venous catheter complication
Coronary Sinus Thrombosis: A Central Venous Catheter Complication By Joseph B. Philips III, N o r m a n Ruiz-Castaneda, and Emmalee S. Setzer Gainesville, Florida 9 This is a report of a fatal thrombotic complication in a centrally alimented premature infant with a venous malformation. INDEX W O R D S : Coronary sinus thrombosis; total parenteral nutrition.
HROMBOTIC COMPLICATIONS of central venous catheters constitute an important source of morbidity and mortality in infants receiving total parenteral nutrition ( T P N ) . Several authors have investigated thrombotic complications in centrally alimented infants. Wilmore j encountered no thromboses in 18 infants on TPN, while Groff 2 observed two patients with superior vena caval thrombosis among 18 patients on T P N for a total of 391 days. Johnson 3 reported 4 of 32 babies with major venous obstruction associated with central venous lines; one of these infants had three separate thrombotic episodes during 308 days of TPN. Filler 4 noted "several" instances of venous thrombosis in septic patients on TPN, but reported no thromboses without sepsis in 134 infants. Altman and Randolph 5 studied 26 infants over an 18-too period and did not see thrombosis as a complication of TPN; however, one patient died when the catheter lodged in the coronary sinus, producing venous obstruction and cardiac tamponade. Most authors state that major venous thromboses resolve over a period of weeks by formation of collateral vessels. Firor, 6 however, reported an infant with fatal pulmonary emboli from mural thrombi in the subclavian and innominate veins occurring nearly 4 wk after discontinuation of the central line.
T
CASE REPORT Baby girl T was the 1360-g black female product of a 31-wk gestation in a 34-yr-old multigravida with chronic hypertension and toxemia. The hospital course was uncomplicated except for mild respiratory distress until 20 days postnatally when the child developed lethargy, abdominal distention and profuse bloody diarrhea. Abdominal radiographs showed dilated loops of bowel without pneumatosis intestinalis or free air. Stool culture grew Salmonella enteritidis. The infant responded to conventional therapy and did well for 2 wk. At 36 days she Journal of Pediatric Surgery, Vol. 16, No. 5 (October), 1981
developed lethargy, vomiting, abdominal distention, dehydration, and severe metabolic acidosis. Cultures of blood, cerebrospinal fluid, stool, and urine all grew Salmonella enteritidis. To facilitate extended parenteral alimentation, a central venous 22 gauge radiopaque silastic catheter was placed via cutdown on the left common facial vein. Radiographically the catheter appeared to be in a persistent left superior vena cava with the tip near the coronary sinus. A radiograph the following day showed that the catheter had entered the region of the coronary sinus. The catheter was pulled back and its position in the left superior vena cava confirmed radiographically without contrast material. Shortly after the last radiograph, the infant suddenly developed gasping, agonal respirations, and profound bradycardia. Resuscitative efforts were unsuccessful and the infant expired. At autopsy the pericardial sac contained 14 ml of clear serous fluid. The central venous line was located within a persistent left superior vena cava which entered the coronary sinus. The catheter tip was approximately 1 cm above the junction of the left superior vena cava and the coronary sinus which was completely occluded by an antemortem thromboembolus. There was no coronary sinus ostium into the right atrium. The persistent left superior vena cava was connected to the right superior vena cava by a large persistent innominate vein. A large left posterior ventricular wall infarct with marked coronary venous engorgement was present. Other postmortem findings included: pulmonary alveolar septal thickening; edema and hyperemia of the small and large bowel; and pericerebellar hemorrhage with extension along the ventral brain stem secondary to an intraventricular hemorrhage.
DISCUSSION V i r c h o w 7 in 1856 p r o p o s e d t h a t t h r o m b i c o u l d result when the triad
of stasis, alteration
of
c o a g u l a t i o n , a n d local t r a u m a or i n f l a m m a t i o n o f a vessel wall o c c u r r e d . O u r p a t i e n t p r e s e n t e d with Salmonella
sepsis and d e h y d r a t i o n , w h i c h
m a y have profoundly altered this triad. Stasis of
From the Department o f Pediatrics, Division o f Neonatology, University o f Florida College o f Medicine, Gainesville, Fla. Supported in part by NIH Growth and Developmental Physiology Training Grant HD 00054-17. Address reprint requests to J. Philips HI, M.D., Department o f Pediatrics, Division o f Perinatal Medicine, 509 New Hillman Building, UAB Medical Center, University Station, Birmingham, Ala. 35294. 9 1981 by Grune & Stratton, Inc. 0022-3468/81/1605-0020501.00/0 733
734
PHILIPS, RUIZ-CASTANEDA, AND SETZER
blood flow within the coronary sinus caused by the a b n o r m a l coronary venous return c o m b i n e d with the presence of a foreign body, mural t r a u ma, r e d u c e d blood volume, sepsis, and possible c o a g u l o p a t h y c o n t r i b u t e d to the f o r m a t i o n of a fatal t h r o m b u s within the c o r o n a r y sinus. O ' R e i l l y 8 has d r a w n attention to the diagnosis of a b e r r a n t c a t h e t e r location within the chest. Careful scrutiny of radiographs following central venous c a t h e t e r p l a c e m e n t is m a n d a t o r y . If the c a t h e t e r tip is within the right a t r i u m or c o r o n a r y sinus, it must be w i t h d r a w n into the superior vena cava. A c a t h e t e r located within a persistent left superior vena cava m a y enter d i r e c t l y the c o r o n a r y sinus. In this situation, the c a t h e t e r must be removed a l t o g e t h e r or withd r a w n until its tip lies high within the vessel. R o u t i n e p l a c e m e n t of central venous c a t h e t e r s
on the right side of the neck will avoid c o r o n a r y sinus catheterization. The incidence of persistent left superior vena cava was 0.3% in a series of over 4000 unselected autopsies. 9 T h e m a j o r i t y of these d r a i n into a dilated c o r o n a r y sinus. W h e n the coronary sinus ostium is absent, then c o r o n a r y venous d r a i n a g e is c e p h a l a d through the persistent left superior vena cava and across the i n n o m i n a t e vein to the normal right superior vena cava. T h r o m b o s i s m a y be u n a v o i d a b l e in some infants. However, careful attention to blood volume, c i r c u l a t o r y status, c o a g u l a t i o n a n d a n a t o m i c a l variants, as well as removal of central lines from patients with d o c u m e n t e d or suspected sepsis should m i n i m i z e the risks of thrombosis within m a j o r vessels.
REFERENCES
1. Wilmore DW, Groff DB, Bishop HC, et al: Total parenteral nutrition in infants with catastrophic gastrointestinal anomalies. J Pediatr Surg 4:181 189, 1969 2. Groff DB: Complications of intravenous hyperalimentation in newborns and infants. J Pediatr Surg 4:460464, 1969 3. Johnson DG: Total intravenous nutrition in newborn surgical patients: A three year perspective. J Pediatr Surg 5:601-605, 1970 4. Filler RM: Total parenteral feeding of infants. Hosp Pract 7:79-87, 1972 5. Altman RP, Randolph JG: Application and hazards of
total parenteral nutrition in infants. Ann Surg 174:85-90, 1971 6. Firor HV: Pulmonary embolization complicating total intravenous alimentation. J Pediatr Surg 7:81, 1972 7. Virchow R: Gesammelte Abhandlungen zur Wissenchaftlichen Medicin. Frankfurt, Verlag Von Meidinger Sohn and Comp, 1856 8. O'Reilly RJ: Aberrant various catheter position within the left chest. Contemp Surg 12:29-33, 1978 9. Bankl H: Congenital malformations of the heart and great vessels. Baltimore Munich, Urban & Schwarzenberg, 1977, pp 193-194
HROMBOTIC COMPLICATIONS of central venous catheters constitute an important source of morbidity and mortality in infants receiving total parenteral nutrition ( T P N ) . Several authors have investigated thrombotic complications in centrally alimented infants. Wilmore j encountered no thromboses in 18 infants on TPN, while Groff 2 observed two patients with superior vena caval thrombosis among 18 patients on T P N for a total of 391 days. Johnson 3 reported 4 of 32 babies with major venous obstruction associated with central venous lines; one of these infants had three separate thrombotic episodes during 308 days of TPN. Filler 4 noted "several" instances of venous thrombosis in septic patients on TPN, but reported no thromboses without sepsis in 134 infants. Altman and Randolph 5 studied 26 infants over an 18-too period and did not see thrombosis as a complication of TPN; however, one patient died when the catheter lodged in the coronary sinus, producing venous obstruction and cardiac tamponade. Most authors state that major venous thromboses resolve over a period of weeks by formation of collateral vessels. Firor, 6 however, reported an infant with fatal pulmonary emboli from mural thrombi in the subclavian and innominate veins occurring nearly 4 wk after discontinuation of the central line.
T
CASE REPORT Baby girl T was the 1360-g black female product of a 31-wk gestation in a 34-yr-old multigravida with chronic hypertension and toxemia. The hospital course was uncomplicated except for mild respiratory distress until 20 days postnatally when the child developed lethargy, abdominal distention and profuse bloody diarrhea. Abdominal radiographs showed dilated loops of bowel without pneumatosis intestinalis or free air. Stool culture grew Salmonella enteritidis. The infant responded to conventional therapy and did well for 2 wk. At 36 days she Journal of Pediatric Surgery, Vol. 16, No. 5 (October), 1981
developed lethargy, vomiting, abdominal distention, dehydration, and severe metabolic acidosis. Cultures of blood, cerebrospinal fluid, stool, and urine all grew Salmonella enteritidis. To facilitate extended parenteral alimentation, a central venous 22 gauge radiopaque silastic catheter was placed via cutdown on the left common facial vein. Radiographically the catheter appeared to be in a persistent left superior vena cava with the tip near the coronary sinus. A radiograph the following day showed that the catheter had entered the region of the coronary sinus. The catheter was pulled back and its position in the left superior vena cava confirmed radiographically without contrast material. Shortly after the last radiograph, the infant suddenly developed gasping, agonal respirations, and profound bradycardia. Resuscitative efforts were unsuccessful and the infant expired. At autopsy the pericardial sac contained 14 ml of clear serous fluid. The central venous line was located within a persistent left superior vena cava which entered the coronary sinus. The catheter tip was approximately 1 cm above the junction of the left superior vena cava and the coronary sinus which was completely occluded by an antemortem thromboembolus. There was no coronary sinus ostium into the right atrium. The persistent left superior vena cava was connected to the right superior vena cava by a large persistent innominate vein. A large left posterior ventricular wall infarct with marked coronary venous engorgement was present. Other postmortem findings included: pulmonary alveolar septal thickening; edema and hyperemia of the small and large bowel; and pericerebellar hemorrhage with extension along the ventral brain stem secondary to an intraventricular hemorrhage.
DISCUSSION V i r c h o w 7 in 1856 p r o p o s e d t h a t t h r o m b i c o u l d result when the triad
of stasis, alteration
of
c o a g u l a t i o n , a n d local t r a u m a or i n f l a m m a t i o n o f a vessel wall o c c u r r e d . O u r p a t i e n t p r e s e n t e d with Salmonella
sepsis and d e h y d r a t i o n , w h i c h
m a y have profoundly altered this triad. Stasis of
From the Department o f Pediatrics, Division o f Neonatology, University o f Florida College o f Medicine, Gainesville, Fla. Supported in part by NIH Growth and Developmental Physiology Training Grant HD 00054-17. Address reprint requests to J. Philips HI, M.D., Department o f Pediatrics, Division o f Perinatal Medicine, 509 New Hillman Building, UAB Medical Center, University Station, Birmingham, Ala. 35294. 9 1981 by Grune & Stratton, Inc. 0022-3468/81/1605-0020501.00/0 733
734
PHILIPS, RUIZ-CASTANEDA, AND SETZER
blood flow within the coronary sinus caused by the a b n o r m a l coronary venous return c o m b i n e d with the presence of a foreign body, mural t r a u ma, r e d u c e d blood volume, sepsis, and possible c o a g u l o p a t h y c o n t r i b u t e d to the f o r m a t i o n of a fatal t h r o m b u s within the c o r o n a r y sinus. O ' R e i l l y 8 has d r a w n attention to the diagnosis of a b e r r a n t c a t h e t e r location within the chest. Careful scrutiny of radiographs following central venous c a t h e t e r p l a c e m e n t is m a n d a t o r y . If the c a t h e t e r tip is within the right a t r i u m or c o r o n a r y sinus, it must be w i t h d r a w n into the superior vena cava. A c a t h e t e r located within a persistent left superior vena cava m a y enter d i r e c t l y the c o r o n a r y sinus. In this situation, the c a t h e t e r must be removed a l t o g e t h e r or withd r a w n until its tip lies high within the vessel. R o u t i n e p l a c e m e n t of central venous c a t h e t e r s
on the right side of the neck will avoid c o r o n a r y sinus catheterization. The incidence of persistent left superior vena cava was 0.3% in a series of over 4000 unselected autopsies. 9 T h e m a j o r i t y of these d r a i n into a dilated c o r o n a r y sinus. W h e n the coronary sinus ostium is absent, then c o r o n a r y venous d r a i n a g e is c e p h a l a d through the persistent left superior vena cava and across the i n n o m i n a t e vein to the normal right superior vena cava. T h r o m b o s i s m a y be u n a v o i d a b l e in some infants. However, careful attention to blood volume, c i r c u l a t o r y status, c o a g u l a t i o n a n d a n a t o m i c a l variants, as well as removal of central lines from patients with d o c u m e n t e d or suspected sepsis should m i n i m i z e the risks of thrombosis within m a j o r vessels.
REFERENCES
1. Wilmore DW, Groff DB, Bishop HC, et al: Total parenteral nutrition in infants with catastrophic gastrointestinal anomalies. J Pediatr Surg 4:181 189, 1969 2. Groff DB: Complications of intravenous hyperalimentation in newborns and infants. J Pediatr Surg 4:460464, 1969 3. Johnson DG: Total intravenous nutrition in newborn surgical patients: A three year perspective. J Pediatr Surg 5:601-605, 1970 4. Filler RM: Total parenteral feeding of infants. Hosp Pract 7:79-87, 1972 5. Altman RP, Randolph JG: Application and hazards of
total parenteral nutrition in infants. Ann Surg 174:85-90, 1971 6. Firor HV: Pulmonary embolization complicating total intravenous alimentation. J Pediatr Surg 7:81, 1972 7. Virchow R: Gesammelte Abhandlungen zur Wissenchaftlichen Medicin. Frankfurt, Verlag Von Meidinger Sohn and Comp, 1856 8. O'Reilly RJ: Aberrant various catheter position within the left chest. Contemp Surg 12:29-33, 1978 9. Bankl H: Congenital malformations of the heart and great vessels. Baltimore Munich, Urban & Schwarzenberg, 1977, pp 193-194