SESSION TITLE: Surgery Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Clamping of the superior vena cava (SVC) or bilateral brachiocaphalic veins (BCV) can be required during thoracic surgery for SVC reconstruction. In such cases, reconstruction without cardiopulmonary bypass may induce hemodynamic instability, cerebral venous hypertension and hypoperfusion.
CASE PRESENTATION: A 63-year-old man was referred to our department for surgical resection of invasive thymoma (type B3) after 2 courses of ADOC therapy (Cisplatin, Doxorubicin, Vincristine, Cyclophosphamide) resulted in stable disease (SD). Resection of the tumor was done through a median sternotomy under monitoring of regional cerebral saturation of oxygen (rSO2) using near-infrared spectroscopy (NIRS). The tumor invaded to the right upper lobe (S3), the right phrenic nerve, the SVC, and the bilateral BCV. Bilateral clamping of the BCVs induced significant decrease in arterial blood pressure (ABP, 98 mmHg to 54 mmHg) and rSO2 (60% to 40%). Fluid infusion or inotropic agents achieved the improvement of the blood pressure, but rSO2 remained low during bilateral clamping of the BCVs. On the other hand, unilateral clamping of the BCV did not have a significant influence on both ABP and rSO2. Therefore, two-staged reconstruction of the SVC and the BCVs was planned. After systemic heparinization (100IU/kg of body weight), resection of the left BCV following proximal ligation and reconstruction between the left BCV and the right atrial appendage with 10mm ringed expanded polytetrafluoroethylene (ePTFE) graft were performed at first. Then, the tumor was excised after concomitant resection of the SVC and the right BCV following respective clamping and partial resection of the right upper lobe. Finally, reconstruction between the right BCV and the proximal SVC with ePTFE graft was performed. Pathological stage of the tumor was T3N0M0 stage III. Although contrast media enhanced revealed occlusion of the left BCV-right atrial appendage bypass, postoperative course was uneventful.
DISCUSSION: Basically, NIRS is a technique that can be used as a noninvasive and continuous monitor of the balance between cerebral oxygen delivery and consumption. Venous hypertension induced by intra-operative obstruction can be an important factor for affecting the cerebral oxygen delivery by decreasing the perfusion pressure. Reconstruction of bilateral BCVs without cardiopulmonary bypass could be done under monitoring of rSO2 using NIRS without hemodynamic instability, cerebral venous hypertension, hypoperfusion, and neurological complications.
CONCLUSIONS: Monitoring of rSO2 using NIRS was useful to suggest cerebral venous hypertension and hypoperfusion induced by bilateral clamping of BCVs.
Reference #1: Murkin JM, Arango M. Near-infrared spectroscopy as an index of brain and tissue oxygenation Br J Anaesth. 103:i3-13, 2009
DISCLOSURE: The following authors have nothing to disclose: Yukio Umeda, Shinsuke Matsumoto, Yoshio Mori, Hiroshi Takiya
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