DOI: 10.1111/jocs.13737
IMAGES IN CARDIAC SURGERY
Large superior vena cava thrombus requiring thrombectomy as a complication of ventriculo-atrial shunt Jeremy Steele MD
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Robert Stewart MD | Rukmini Komarlu MD |
Hani Najm MD Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio Correspondence Jeremy Steele MD, Cleveland Clinic Children's Hospital, Department of Pediatric Cardiology, 9500 Euclid Avenue. Cleveland, OH 44195. Email:
[email protected]
Superior vena cava (SVC) thrombosis is a recognized complication
mean gradient was 6 mmHg with flow seen around the thrombus by
of ventriculo-atrial (VA) shunts.1 We present images of a patient
color Doppler (Figure 1). Heparin infusion was initiated and the
who developed a large SVC thrombus following a VA shunt which
patient was transitioned to subcutaneous injections with achieve-
required a thrombectomy. A 2-year-old, African-American, ex-26-
ment of therapeutic anti-Xa levels. TTEs showed a failed response to
week preemie male with history of protein C deficiency, dural sinus
medical therapy despite 9 days of antibiotic and 6 days of
venous thrombosis, and need for ventriculo-peritoneal shunt
anticoagulation therapy.
presented with wound dehiscence in the area of the shunt closure
In view of the failure of the thrombus to resolve and the concern
and positive cerebrospinal fluid cultures for Staphylococcus aureus.
for infectious thromboemboli, the patient was taken to the operating
Three months prior he underwent shunt revision and placement of
room for a thrombectomy of the SVC. An intraoperative transtho-
a right cystoatrial and left VA shunt. Vancomycin therapy was
racic echocardiogram (TEE) showed that the thrombus was 2 cm in
initiated. His cardiac exam was remarkable for a grade II/VI low-
length with a pedicle of 1.0 × 1.5 cm (Figure 2). Following a median
pitched, holosystolic murmur along the left sternal border.
sternotomy and systemic heparinization, cardiopulmonary bypass
A transthoracic echocardiogram (TTE) revealed a large lobulated,
(CPB) was instituted for 13 min with cannulas placed in the
pedunculated mobile right atrial mass, measuring 1 × 1.6 cm with a
ascending aorta and the inferior vena cava. The aorta was cross-
stalk that extended into the SVC to the innominate vein. The SVC
clamped and the heart was arrested with del Nido cardioplegia for
FIGURE 1 Preoperative transthoracic echocardiogram: (A) Sub-costal short axis view showing the presence of large thrombus (arrows) extending through the length of the SVC and into the RA. B, Color Doppler demonstrates that the thrombus is only partially occlusive. C, Apical 5-chamber view showing the thrombus abutting against the TV. RA, right atrium; SVC, superior vena cava; TV, tricuspid valve J Card Surg. 2018;1–2.
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FIGURE 2 Intraoperative transesophageal echocardiogram: (A) Bicaval view with the stalk of the thrombus (arrow) occupying the length of the SVC and the pedicle in the RA. The stalk measured approximately 2 cm in length and the pedicle 1 × 1.5 cm. B, Color compare image of the RAA and SVC in cross section demonstrating flow around the thrombus (arrow). RA, right atrium; RAA, right atrial appendage; SVC, superior vena cava
FIGURE 3 A, Intraoperative transesophageal echocardiogram post thrombectomy: No residual thrombus seen in the SVC. B, Color Doppler through the SVC showing laminar flow without any residual obstruction. C, Surgical specimen of the excised thrombus. The stalk and pedicle are clearly seen with a total thrombus length of nearly 3.5 cm. SVC, superior vena cava
8 min. An incision was made in the right atrium (RA) parallel to the atrioventricular groove and the thrombus was completely extracted from the SVC and the innominate vein (Figure 3C). The RA was
ORCID Jeremy Steele
http://orcid.org/0000-0003-3121-3036
closed primarily and the patient was weaned off CPB without difficulty. A post CPB TEE showed no residual thrombus and normal laminar flow in the SVC without any obstructions (Figures 3A and 3B). The patient had an uncomplicated postop course. His tricuspid
REFERENCE
murmur resolved and the clot grew out no organisms. He received 3
1. Tonn P, Gilsbach J M, Kreitschmann-Andermahr I, Franke A, Blindt R. A rare but life-threatening complication of ventriculo-atrial shunt. Acta Neurochir (Wien). 2005;147:1303–1304.
months of low-molecular-weight heparin. He continues to do well off all anticoagulant therapy.
CONFLICTS OF INTEREST
How to cite this article: Steele J, Stewart R, Komarlu R, Najm H. Large superior vena cava thrombus requiring
The authors of this paper have no declarations. No grants or financial
thrombectomy as a complication of ventriculo-atrial shunt.
support has been received. There are no conflicts of interest. This
J Card Surg. 2018;1–2. https://doi.org/10.1111/jocs.13737
paper is not currently under consideration elsewhere.
