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OBJECTIVE: Iatrogenic vascular injury from hemodialysis catheters can be safely managed via median sternotomy. Minimally invasive approaches may be useful in selected situations for hemodynamically stable patients. The objective of this report is to present the first known case of iatrogenic SVC perforation managed with a partial sternotomy.
METHODS: The chart of an elderly patient who sustained an iatrogenic SVC perforation was reviewed. The evaluation, operative techniques and considerations will be presented.
RESULTS: A 76 year old woman underwent an attempt to place a hemodialysis catheter via the left subclavian vein. Due to suspicion of perforation of the lateral aspect of the SVC, the procedure was aborted, the catheter was left in place, and contrast CT angiography of the chest revealed an extraluminal position of the catheter tip. The patient was hemodynamically stable. After intubation, TEE showed no other significant pathology. On-table angiography showed no other major vascular disruption. As a result, a partial upper sternotomy (J-incision) was made into the right 4th interspace. The pericardium was opened, the SVC was exposed along its length and the extravascular position of the catheter was noted. A 4-0 Prolene pledgeted suture was placed around the perforation site and the catheter was withdrawn as the suture was tied down. The sternum was rewired in standard fashion, and the patient recovered uneventfully
CONCLUSIONS: To the best of our knowledge, this represents the first known case of a partial upper sternotomy to manage iatrogenic perforation of the SVC. This approach offers advantages over other minimally invasive strategies in its ability to expeditiously place a patient on cardiopulmonary bypass, and may be useful in selected, hemodynamically stable patients.