[HSF] Occluded SVC

[Nasser F. Abou'Seada]

Dear Hal
what is meant by "non-circumferential intimal tears" ... ? .... you
mentioned a "substantial venous blood coming from beneath the SVC and IVC"
...... through perculation you mean ! ....I did have that situation before
in the IJV caused by a faulty trial of insertion of an IJV Cannula by the
anaesthesiologist ..... diagnosed PM !!!! .........   how could you
determine the sites of the tears ??? ..... . what sort of external suturing
and sutures did you apply there ?? .... To which "side" of the SVC / IVC
the sutures were applied ??? ?? .... I mean median? lateral? posterior ???
... were these under vision or blind stitches ??? . .... how
"circumferential" were the stitches ??? ..... did any of these stitches has
purse string effects on the lateral wall ??? ....  Do you feel that the SVC
have become stenotic - dysfigured thereafter? ??? .....

When did the patient present postop with signs of SVC obstruction  ? ....
thrombosis is unlikely to form postoperatively should coumadin have been
instituted for the AVR ..... even with a dysfigured wall ...  . obstruction
then would be from another reason .... again .... do you feel it was
stenotic - disfigured after your stitches ?? ...

else-wise .... Was the pacemaker transvenous ??? .... any possibility that
its insertion might have been the exciting factor in the obstruction ????
deploying a stent here might just complicate the situation ..!!!
Sure the patient has got a gradient across the SVC .......... that can be
multifactorial ........ still ,.. his drainage is compensating and time is
in his favour .....
I would consider, in case of any doubt of thrombus, a targeted catheter
induced thrombolysis, otherwise I would - should I feel it is a stenotic
rather than thrombotic problem - go on and insert an onlay patch-plasty
....

Complicated operations have been undertaken for much trivial reasons !!!

Good luck with your case .....

Ani ??? .... comments ????

NFA



On Jan 31, 2008 6:11 AM, <Hgrmd at aol.com> wrote:

> Dear Members,
>  First, it was such a pleasure to meet several of you for the first  time
> at
> the HSF dinner.
>  I need some urgent advice.  About 2 weeks ago, I did a redo  AVR, mitral
> repair, tricuspid repair, Cox-maze on a 75 yo man.  Intraop,  while
> retracting
> the atrial septum for the work in the LA, noncircumferential  intimal
> tears
> developed on both the SVC and IVC.  I could tell because  there was
> substantial
> venous blood coming from underneath the SVC and IVC.   I was able to
> repair
> both with external suturing.  The rest of the case  went well.  About a
> week
> later, we inserted a DDD pacemaker (the patient  had been in continuous AF
> for
> years).  A few days later, he developed  severe facial and upper extremity
> swelling.  Workup reveals he has an  occluded SVC.  The cardiologist took
> him to the
> lab and measured a 30 mm  gradient across the SVC.  The patient is
> ambulating
> well and generally  feels OK, but he has the persistent swelling.  There
> is
> no evidence of  symptomatic intracranial swelling or upper airway
> compromise.
> The  cardiologist insists something must be done.  I'm reluctant to have a
> stent  deployed in a fresh heart.  The surgical option would be to extract
> the
> thrombus on CPB and patch the SVC.  My question is:  Is it  justified?
>
> Hal
>
>
>
> **************Start the year off right.  Easy ways to stay in shape.
> http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489
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