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Fatal haemothorax following large-bore percutaneous cannulation before liver transplantation
- Davinia G Bennett, John L. Isaac and Darius F. Mirza (9 January 2006)
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Haemothorax following large-bore percutaneous cannulation for liver transplantation
- Olumuyiwa A Bamgbade (21 October 2005)
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Transoesophageal Echocardiography in SVC cannulation
- Rahul Basu, Prabhat Tewari (7 October 2005)
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Davinia G Bennett, SpR Anaesthesia Birmingham Liver Unit, John L. Isaac and Darius F. Mirza
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Editor - We would like to thank Dr Jankovic et al for drawing attention to the significant risks associated with the insertion of percutaneous bypass cannulae for veno-venous bypass in patients undergoing orthotopic liver transplantation (OLT). In 2001 Birmingham Liver Unit published a series of 312 cases to review the morbidity and mortality associated with veno-venous bypass cannulae (VVBC). The incidence of morbidity and mortality was 1.28% and 0.32% respectively. Also highlighted were some risk factors for complications e.g. difficulty inserting the guide-wire, use of the subclavian route etc. In view of the significant complications and a change in institutional practice the Birmingham Liver Unit adopted the “piggyback “technique exclusively, which negates the need for insertion of VVBC. We regret that the authors omitted to highlight this alternative surgical technique and its inherent advantages. Concerns that there are significant risks associated with the “piggyback technique” (PT) e.g. acute Budd-Chiari , have been refuted, with various institutions comparing the conventional technique i.e. using bypass with the piggyback technique and finding no difference in outcome . Our unit is soon to publish outcome data before and after commencing use of the piggyback technique (PT). Our surgeons found several advantages when using PT such as a decrease in blood usage, a reduction in cold ischaemic time and an overall reduction in post operative ventilation time and ITU stay. Naturally, there were no complications due to VVBC. There were 3/246 (1.2%) cases of caval outflow obstruction in those where PT was used. These were identified early and radiologically managed. We believe that VVB is no longer the technique of choice for OLT and that the mortality reported by Dr Jankovic would not have occurred had PT been used. A change in surgical practice will prevent further unnecessary mortality and morbidity from VVBC insertion. 1.Jankovic Z, Boon A, Prasad R. Fatal haemothorax following large- bore percutaneous cannulation before liver transplantation. Br J Anaesth 2005; 95(4):472-476. 2.Budd JM, Isaac JL, Bennett J, Freeman JW. Morbidity and mortality associated with large-bore percutaneous veno-venous bypass cannulation for 312 orthotopic liver transplantations. Liver Transpl 2001; 7(4):359-362. 3.Parilla P, Sanchez-Bueno F, Figueras J, Jaurrieta E, Mir J, Margarit C, et al. Analysis of the complications of the piggy-back technique in 1112 liver transplants. Transplantation 1999;67:1214-1217. 4.Navarro F, Le Moine M-C, Fabre J-M, Belghiti J, Cherqui D, Adams R, et al. Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava: Review of 1361 cases. Transplantation 1999;68:646-650. 5.Miyamoto S, Polak WG, Geuken E, et al. Liver transplantation with preservation of the inferior vena cava. A comparison of conventional and piggyback techniques in adults. Clin Transplant 2004; 18(6):686-93. Thanks the Mr M.A. Silva MS FRCS Ed for providing the current Birmingham surgical data. Conflict of Interest:None declared |
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Olumuyiwa A Bamgbade, Attending Anesthesiologist University of Michigan Hospital, Ann Arbor, USA
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Editor – The report by Jankovic and colleagues of fatal haemothorax from large-bore jugular vein cannulation was interesting[1]. Percutaneous cannulation for venovenous bypass is certainly quicker and less complicated than the venous cut-down technique[2]. The internal jugular (IJ) route is associated with failure (7%) and vein rupture with or without haemothorax(<2%)[2]. Haemothorax from central venous cannulation is rare(<1%)[2,3,4]. The reported misplacement of the bypass cannula into the right pleural cavity may be due to many factors. The high number of guidewires (3 wires) inserted in the IJ vein increased the risk of wire displacement or coiling. This may be responsible for the difficult insertion of the third wire. Difficult wire insertion and more than one venous puncture are risk factors for complications[3]. Does liver transplantation require so many venous access, and do all patients require bypass? The practice at the University of Michigan Hospital is the insertion of a 9 Fr sheath and a 14 Fr bypass cannula in the right IJ vein. The 14 Fr cannula is usually used for rapid infusion. If bypass is required during the anhepatic phase because of severe cardiovascular instability, another 14 Fr bypass cannula is inserted into the left femoral vein by the surgeons and used with the right IJ bypass cannula for venovenous bypass. However, less than 20% of our liver transplantations require venovenous bypass. Jankovic and colleagues rightly admitted that the rigid end of the guidewire should not have been inserted instead of the J-portion; the rigid wire may have perforated the superior vena cava in the case reported. The rigid end of the wire is unlikely to turn laterally into the right subclavian vein as was suggested. The resistance to guidewire withdrawal is an indication of wire misplacement or trapping in vascular or thoracic tissue. Such situations usually require removal of the guidewire and dilator together as a whole. It is of note that the guidewires used in the case were inserted to a depth of 30cm, and a 60cm dilator was used! These are excessively long devices and greatly increase the risk of vascular or cardiac injury, if the optimal length of insertion is mis-judged[4,5]. Although the aspiration of blood and flushing of the bypass catheter appeared normal, it was likely that haemothorax blood was being aspirated; and there are case reports of this problem[6]. This discussion highlights the possible causes of error in percutaneous large-bore central vein cannulation that anaesthesiologists or intensivists may encounter in routine practice. A high index of suspicion aids prompt diagnosis of haemothorax; and detection by plain chest radiography is unreliable[4]. Dysfunctional or suspicious central venous devices should never be used, but carefully removed in a most appropriate way. References: 1-Jankovic Z, Boon A, Prasad R. Fatal haemothorax following large-bore percutaneous cannulation before liver transplantation. Br J Anaesth 2005; 95: 472-6. 2-Pranikoff T, Hirschl RB, Remenapp R, Swaniker F, Bartlett RH. Venovenous extracorporeal life support via percutaneous cannulation in 94 patients. Chest 1999; 115: 818-22. 3-Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy: a prospective audit. Intensive Care Med 1999; 25: 481-5. 4-Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD. Perforation of the great vessels during central venous line placement. Arch Intern Med 1995;155:1225-8. 5-Oropello JM, Leibowitz AB, Manasia A, Del G, Benjamin E. Dilator- associated complications of central vein catheter insertion: possible mechanisms of injury and suggestions for prevention. J Cardiothorac Vasc Anesth 1997; 10: 634-7. 6-Knottenbelt JD, Bautz P. Haemothorax: a source of error in emergency central vein cannulation. South Afr J Surg 1993; 31: 120-1. Conflict of Interest:None declared |
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Rahul Basu, Anaesthetist Nottingham City Hospital, Prabhat Tewari
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To The Editor, British Journal of Anaesthesia Dear Sir, We read with interest the case report by Jankovic and colleagues who reported fatal haemothorax following a misplaced percutaneous Superior Vena Cava (SVC) cannula for orthotopic liver transplantation (OLT). We feel that the use of Transoesophageal Echocardiography (TOE) can confirm the correct placement of an SVC cannula with a greater degree of certainty. In our practise we routinely place percutaneous SVC cannulae for minimally invasive cardiac procedures. The TOE probe is inserted prior to cannula placement. The guidewire in the Right Atrium (RA) and subsequently the cannula tip position in the SVC- RA junction are confirmed in the bicaval view. The authors’ concerns that a significant number of patients presenting for OLT may have oesophageal varices are valid. We, however, feel that the presence and extent of varices can be identified in the preoperative workup for these patients. For those who have significant varices an option could be to assess the exact position of the varices and the insert TOE probe accordingly. As the bicaval view is obtained in the mid oesophagus TOE insertion should be safe in the majority of patients. Thanking you Yours sincerely Dr Rahul Basu, Dr Prabhat Tewari, Department of Anaesthesia, Nottingham City Hospital. Email: rbasu@ncht.trent.nhs.uk 1. Jankovic Z, Boon A, Prasad R . Fatal haemothorax following large bore percutaneous cannulation before liver transplantation. BJA 2005 95(4) 472-6 Conflict of Interest:None declared |
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