- Email: [email protected]
Disruption of Left Brachiocephalic Vein
302 The Annals of Thoracic Surgerq. Vol 38 No 3 September 1984
Disruption of Left Brachiocephalic Vein To the Editor: We found the article by Drs. de Boer and Homan van der Heide entitled “Interposition of a Composite Venous Autograft for the Treatment of a Ruptured Left Brachiocephalic Vein” (Ann Thorac Surg 36:607, 1983) informative, but we wish to offer a simpler technique that has proven useful in managing the same problem. When we have been faced with disruption of the left brachiocephalic vein from the superior vena cava (two instances), we have used pericardial patches to repair the disruption. The pericardium is readily available and requires no suturh g to construct a patch of appropriate diameter. In both cases, we gave systemic heparin (3 mg per kilogram of body weight, administered intravenously) to the patients before applying small vascular clamps to the superior vena cava and the right and left brachiocephalic veins. Digital compressionof the injury sites was necessary to minimize blood loss while the heparin was being administered and while sufficientdissection was performed to allow safe placement of the vascular clamps. The pericardial patches were tailored and sewn in place in the rent in both patients with running sutures of 6-0 Prolene. The inner side of the pericardium was placed toward the luminal aspect of the repair in both instances. The patients underwent coronary artery bypass operations immediately after the venous repair. Both had uneventful postoperative courses and were discharged from the hospital seven days after operation. We suggest that the pericardial patch technique allows appropriate reconstruction of the left brachiocephalic vein without requiring multiple long suture lines to construct a patch or a tube interposition graft. Furthermore, the saphenous vein does not have to be harvested before the patch is constructed. Thus, the pericardial patch technique should theoretically save time and minimize the length of suture line, which could contribute to hemorrhage after cardiopulmonary bypass.
Geoffrey M . Graeber, M.D., LTC, MC, USA Stephen M . Fall, M . D . , LTC, MC, USA Cardiothoracic Surgey Service Walter Reed Army Medical Center Washington, DC 20307
Reply To the Editor: We thank Drs. Graeber and Fall for their remarks. The technique they suggest has also been performed by us in a number of patients. However, it should be considered that the composite venous autograft we described in our article is a vessel tube, for which there are a number of applications: (1) when it is impossible to overbridge the defect by using venous or pericardial patch grafts, as in the case of a ruptured left brachiocephalic vein; (2) to improve quality of life in the case of a superior vena caval obstruction due to benign or malignant disease 111; and (3) at other sites to fashion a conduit in the venous system. As coronary bypass surgery may be indicated in the future, one should of course be as economical as possible in using the great saphenous vein.
W . 1. de Boer, M . D . 1. N . Homan van der Heide, M . D . , Ph D . Division of Cardiopulmonay Surgey University Hospital Oostersingel 59 9713 EZ, Groningen, The Netherlands
Reference 1. Doty BD Bypass of superior vena cava. J Thorac Cardiovasc Surg 83:326, 1982
Surgical Salvage of Heart Rupture To the Editor: Bashour and colleagues [l] recently reported in The Annals on cardiac rupture, a common entity that frequently can be treated. Cardiac rupture is one of the most common causes of death following acute myocardial infarction, yet investigation of this condition has been neglected. Surprisingly, it has been accepted that ventricular rupture following acute myocardial infarction is a hopeless situation. With such a desperate and erroneous concept, heart rupture will remain a hopeless complication of myocardial infarction. However, patients with ventricular rupture die to pericardial tamponade, which is a treatable condition. There is another erroneous concept involved here: Rupture of the heart produces a very rapid tamponade and death within a few seconds or minutes, and patients who survive hours or days are considered medical curiosities, worthy of being written up and published. Cardiac tamponade and heart rupture represent a spectrum. Leakage of blood in the pericardial cavity may be sudden or slow, and we know that cardiac rupture is often slow and progressive [2]. Cases with slow accumulation of blood in the pericardial cavity have been observed in many circumstances, and these can be diagnosed early enough for surgical intervention. We [3] have reported on 10 patients who all underwent operation for heart rupture at the same institution. Our experience now includes 21 patients with 6 long-term survivors after more than two years of follow-up. We have more than half of all successfully treated cases in the world literature. More important, the number of patients diagnosed to have this condition is increasing, along with the experience for diagnosis. Our cardiologists are convinced that making the diagnosis of heart rupture may save the life of the patient. The diagnosis may be strongly suspected at bedside [4] even when the general clinical condition of the patient has not deteriorated. Operation is performed immediately. We have lost several patients because of delay in diagnosis or operation, and we firmly believe that any maneuver that delays operation should be avoided. Ventriculographyand insertion of circulatory assist devices do not provide useful information or improve the circulatory status of the patient, but they will delay the release of tamponade. We strongly recommend three lines of investigation: (1) identification of high-risk patients; (2) investigation of accurate, quick, easy, and preferably noninvasive methods of diagnosis, such as echocardiography; and (3) development and control of surgical procedures. The message of Bashour and colleagues is a very important one: ”(Alttempts to salvage these critically ill patients are worthwhile.” We would add that suspicion of tamponade, quick confirmation, and urgent operation will save many of these patients-and attempts to save them are not only worthwhile but mandatory.
L. Ndriez, M . D . Chi@, Cardiac Surgey Hospital Clinic0 Sun Carlos Universidad Cornplutense Madrid, Spain
1. Lbpez-Sendbn, M.D.
Coronay Care Unit Cuidad Sanitaria “La Paz” Madrid, Spain
Disruption of Left Brachiocephalic Vein To the Editor: We found the article by Drs. de Boer and Homan van der Heide entitled “Interposition of a Composite Venous Autograft for the Treatment of a Ruptured Left Brachiocephalic Vein” (Ann Thorac Surg 36:607, 1983) informative, but we wish to offer a simpler technique that has proven useful in managing the same problem. When we have been faced with disruption of the left brachiocephalic vein from the superior vena cava (two instances), we have used pericardial patches to repair the disruption. The pericardium is readily available and requires no suturh g to construct a patch of appropriate diameter. In both cases, we gave systemic heparin (3 mg per kilogram of body weight, administered intravenously) to the patients before applying small vascular clamps to the superior vena cava and the right and left brachiocephalic veins. Digital compressionof the injury sites was necessary to minimize blood loss while the heparin was being administered and while sufficientdissection was performed to allow safe placement of the vascular clamps. The pericardial patches were tailored and sewn in place in the rent in both patients with running sutures of 6-0 Prolene. The inner side of the pericardium was placed toward the luminal aspect of the repair in both instances. The patients underwent coronary artery bypass operations immediately after the venous repair. Both had uneventful postoperative courses and were discharged from the hospital seven days after operation. We suggest that the pericardial patch technique allows appropriate reconstruction of the left brachiocephalic vein without requiring multiple long suture lines to construct a patch or a tube interposition graft. Furthermore, the saphenous vein does not have to be harvested before the patch is constructed. Thus, the pericardial patch technique should theoretically save time and minimize the length of suture line, which could contribute to hemorrhage after cardiopulmonary bypass.
Geoffrey M . Graeber, M.D., LTC, MC, USA Stephen M . Fall, M . D . , LTC, MC, USA Cardiothoracic Surgey Service Walter Reed Army Medical Center Washington, DC 20307
Reply To the Editor: We thank Drs. Graeber and Fall for their remarks. The technique they suggest has also been performed by us in a number of patients. However, it should be considered that the composite venous autograft we described in our article is a vessel tube, for which there are a number of applications: (1) when it is impossible to overbridge the defect by using venous or pericardial patch grafts, as in the case of a ruptured left brachiocephalic vein; (2) to improve quality of life in the case of a superior vena caval obstruction due to benign or malignant disease 111; and (3) at other sites to fashion a conduit in the venous system. As coronary bypass surgery may be indicated in the future, one should of course be as economical as possible in using the great saphenous vein.
W . 1. de Boer, M . D . 1. N . Homan van der Heide, M . D . , Ph D . Division of Cardiopulmonay Surgey University Hospital Oostersingel 59 9713 EZ, Groningen, The Netherlands
Reference 1. Doty BD Bypass of superior vena cava. J Thorac Cardiovasc Surg 83:326, 1982
Surgical Salvage of Heart Rupture To the Editor: Bashour and colleagues [l] recently reported in The Annals on cardiac rupture, a common entity that frequently can be treated. Cardiac rupture is one of the most common causes of death following acute myocardial infarction, yet investigation of this condition has been neglected. Surprisingly, it has been accepted that ventricular rupture following acute myocardial infarction is a hopeless situation. With such a desperate and erroneous concept, heart rupture will remain a hopeless complication of myocardial infarction. However, patients with ventricular rupture die to pericardial tamponade, which is a treatable condition. There is another erroneous concept involved here: Rupture of the heart produces a very rapid tamponade and death within a few seconds or minutes, and patients who survive hours or days are considered medical curiosities, worthy of being written up and published. Cardiac tamponade and heart rupture represent a spectrum. Leakage of blood in the pericardial cavity may be sudden or slow, and we know that cardiac rupture is often slow and progressive [2]. Cases with slow accumulation of blood in the pericardial cavity have been observed in many circumstances, and these can be diagnosed early enough for surgical intervention. We [3] have reported on 10 patients who all underwent operation for heart rupture at the same institution. Our experience now includes 21 patients with 6 long-term survivors after more than two years of follow-up. We have more than half of all successfully treated cases in the world literature. More important, the number of patients diagnosed to have this condition is increasing, along with the experience for diagnosis. Our cardiologists are convinced that making the diagnosis of heart rupture may save the life of the patient. The diagnosis may be strongly suspected at bedside [4] even when the general clinical condition of the patient has not deteriorated. Operation is performed immediately. We have lost several patients because of delay in diagnosis or operation, and we firmly believe that any maneuver that delays operation should be avoided. Ventriculographyand insertion of circulatory assist devices do not provide useful information or improve the circulatory status of the patient, but they will delay the release of tamponade. We strongly recommend three lines of investigation: (1) identification of high-risk patients; (2) investigation of accurate, quick, easy, and preferably noninvasive methods of diagnosis, such as echocardiography; and (3) development and control of surgical procedures. The message of Bashour and colleagues is a very important one: ”(Alttempts to salvage these critically ill patients are worthwhile.” We would add that suspicion of tamponade, quick confirmation, and urgent operation will save many of these patients-and attempts to save them are not only worthwhile but mandatory.
L. Ndriez, M . D . Chi@, Cardiac Surgey Hospital Clinic0 Sun Carlos Universidad Cornplutense Madrid, Spain
1. Lbpez-Sendbn, M.D.
Coronay Care Unit Cuidad Sanitaria “La Paz” Madrid, Spain