Novel Technique for Repair of Innominate Vein Transection During Sternotomy
Presented During:
Saturday, May 6, 2023: 5:00PM - Tuesday, May 9, 2023: 5:00PM
Los Angeles Convention Center
Posted Room Name:
ePoster Area, Exhibit Hall
Abstract No:
6383
Submission Type:
Cardiothoracic Resident Case Report Competition
Authors:
Andrew Gorton (1), Suresh Keshavamurthy (2), Michael Sekela (3)
Institutions:
(1) University of Kentucky, Lexington, KY, United States, (2) University of Kentucky, Lexington, KY, (3) N/A, Lexington, KY
Submitting Author:
Andrew Gorton
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University of Kentucky
University of Kentucky
Co-Author(s):
Suresh Keshavamurthy
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University of Kentucky
University of Kentucky
Michael Sekela
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Presenting Author:
Andrew Gorton
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Abstract:
The innominate vein may be injured during redo or initial median sternotomy due to the anatomical location of the vessel crossing from the left side of the body to the right. It courses anteriorly to the aortic arch and is usually protected by thymic and pericardial adipose tissue. In the case of redo sternotomy,this tissue has usually been violated and the innominate vein may have little distance from the posterior shelf of the sternum. Can also be tethered due to indwelling pacing leads. In first-time sternotomy, the risk is decreased but still present if perfect technique is not followed. We have developed a technique for repair utilizing autologous saphenous vein tissue to create a spiral vein graft.
The most important step in repairing an injury to the innominate vein is first recognizing that the injury has occurred and to control the bleeding. This can often be accomplished without significantly disrupting the flow of the planned procedure. Once on cardiopulmonary bypass, the right sided aspect of the innominate vein will be controlled by venous drainage, but the left side may require a field sucker. We prefer to use a pediatric vent for this purpose. At this point, the remainder of the planned operation may be completed. Approximately 2 standard lengths of saphenous vein are harvested and marked as usual. The vein is split along the midline in the direction of blood flow. We then wrap the vein around a 5cc syringe with the intimal layer towards the plastic, envisioning a barber pole, and suture it together along the edges using 6-0 prolene continuous sutures. We perform the anastomoses with our spiral vein graft using 5-0 prolene continuous sutures. The right side of the innominate vein is completed first while on cardiopulmonary bypass with vacuum assisted drainage. Then the left side of the anastomosis using the pediatric vent for clearing the field. The anastomoses may be performed during rewarming allowing for weaning off cardiopulmonary bypass once complete.
Innominate vein injury is a known complication of median sternotomy, and while avoidance is the best practice, this technique allows for repair using the patient's own tissue. Close attention to pre-operative imaging can help avoid injury in re-operations by planning for alternative strategies prior to sternotomy.
The most important step in repairing an injury to the innominate vein is first recognizing that the injury has occurred and to control the bleeding. This can often be accomplished without significantly disrupting the flow of the planned procedure. Once on cardiopulmonary bypass, the right sided aspect of the innominate vein will be controlled by venous drainage, but the left side may require a field sucker. We prefer to use a pediatric vent for this purpose. At this point, the remainder of the planned operation may be completed. Approximately 2 standard lengths of saphenous vein are harvested and marked as usual. The vein is split along the midline in the direction of blood flow. We then wrap the vein around a 5cc syringe with the intimal layer towards the plastic, envisioning a barber pole, and suture it together along the edges using 6-0 prolene continuous sutures. We perform the anastomoses with our spiral vein graft using 5-0 prolene continuous sutures. The right side of the innominate vein is completed first while on cardiopulmonary bypass with vacuum assisted drainage. Then the left side of the anastomosis using the pediatric vent for clearing the field. The anastomoses may be performed during rewarming allowing for weaning off cardiopulmonary bypass once complete.
Innominate vein injury is a known complication of median sternotomy, and while avoidance is the best practice, this technique allows for repair using the patient's own tissue. Close attention to pre-operative imaging can help avoid injury in re-operations by planning for alternative strategies prior to sternotomy.
Category:
Adult Cardiac
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