NOTE
Absent Left Innominate Vein Sign of Persistent Left Superior Vena Cava Joe R. Utley, M.D., and Kazi Mobin-Uddin, M.D. ABSTRACT Absence of the left innominate vein is a reliable sign of persistence of the left superior vena cava. We have used this sign to determine the presence of a left superior vena cava when performing corrective procedures in patients with congenital heart lesions who have had previous palliative operations. It is useful for the surgeon to recognize persistent left superior vena cava before instituting bypass. One can then determine if the vessel can be safely occluded or if it must be cannulated. This decision can be made at the operating table and does not require preoperative assessment of the collateral drainage of the left superior caval system.
A
nomalous systemic venous return through a persistent left superior vena cava (LSVC), if not recognized prior to instituting cardiopulmonary bypass, may complicate the correction of lesions through the right atrium or ventricle. This is particularly true if the patient has had a previous palliative operation such as pulmonary artery banding or a Blalock-Hanlon or Waterston procedure. Absence of the left innominate vein is a reliable sign of persistence of the LSVC.
Materials a n d Results Sixty-six patients had correction of congenital heart lesions which involved right atriotomy. Lesions included atrial septal defect, pulmonic stenosis, ventricular septal defect, tetralogy of Fallot, and transposition of the great vessels. All operations were done through a median sternotomy. Presence of the left innominate vein was verified in the superior mediastinum, resecting the thymus if necessary. The fold of Marshal anterior From the Division of Cardiothoracic Surgery, University of Kentucky School of Medicine, Ixxington, Ky. Accepted for publication July 8, 1974. Add.ress reprint requests to Dr. Utley, Division of Cardiothoracic Surgery, University of Kentucky School of Medicine, 800 Rose St., Lexington, Ky. 40504.
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to the left pulmonary artery was examined for presence of an 1,SVC. Extracoronary venous drainage into the coronary sinus was demonstrated by blood flow from the coronary sinus when the aorta was clamped. Seven patients had absent left innominate vein, persistent LSVC, and extracoronary blood flow to the coronary sinus; 59 had no LSVC, a normal left innominate vein, and no extracoronary coronary sinus flow ( p < 0.001, Fischer’s exact chi-square test).
Comment Although Winter [Z] originally described the relationship of absent left innominate vein and LSVC, the surgical usefulness of this relationship has not been described. By using this sign as evidence of persistent LSVC, we have been better able to plan the operative approach to certain congenital heart lesions. If the persistent LSVC can be identified and controlled with an umbilical tape prior to instituting cardiopulmonary bypass, one may be able to determine if LSVC occlusion produces high venous pressures and venous engorgement of the head. We would cannulate the LSVC through the coronary sinus if venous engorgement occurred. If cannulation of the LSVC is required, the appropriate triple-cannula venous drainage system can be set u p prior to beginning cardiopulmonary bypass. Although the complications of LSVC occlusion are not well documented, we have had no central nervous system dysfunction when this technique was employed. Freed and his colleagues [13 mentioned cerebral complications following LSVC occlusion. They have described techniques of evaluating a persistent LSVC with balloon occlusion preoperatively. Because evidence of persistent LSVC is usually lacking in small infants when cardiac catheterization is performed through the femoral vein, we have found the absent left innominate vein to be a useful sign. We usually place a left central venous pressure catheter when operating on patients in whom occlusion of the LSVC might be necessary. We can thereby determine the safety of LSVC occlusion or the adequacy of drainage.
R ef erences 1. Freed, M. D., Rosenthal, A., and Bernhard, W. F. Balloon occlusion of a
persistent left superior vena cava in the pre-operative evaluation of systemic venous return. J Thorac Cardiouasc Surg 65:835, 1973. 2. Winter, F. S. Persistent left superior vena cava. Angiology 5:90, 1954.
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THE ANNALS OF THORACIC SURGERY
Absent Left Innominate Vein Sign of Persistent Left Superior Vena Cava Joe R. Utley, M.D., and Kazi Mobin-Uddin, M.D. ABSTRACT Absence of the left innominate vein is a reliable sign of persistence of the left superior vena cava. We have used this sign to determine the presence of a left superior vena cava when performing corrective procedures in patients with congenital heart lesions who have had previous palliative operations. It is useful for the surgeon to recognize persistent left superior vena cava before instituting bypass. One can then determine if the vessel can be safely occluded or if it must be cannulated. This decision can be made at the operating table and does not require preoperative assessment of the collateral drainage of the left superior caval system.
A
nomalous systemic venous return through a persistent left superior vena cava (LSVC), if not recognized prior to instituting cardiopulmonary bypass, may complicate the correction of lesions through the right atrium or ventricle. This is particularly true if the patient has had a previous palliative operation such as pulmonary artery banding or a Blalock-Hanlon or Waterston procedure. Absence of the left innominate vein is a reliable sign of persistence of the LSVC.
Materials a n d Results Sixty-six patients had correction of congenital heart lesions which involved right atriotomy. Lesions included atrial septal defect, pulmonic stenosis, ventricular septal defect, tetralogy of Fallot, and transposition of the great vessels. All operations were done through a median sternotomy. Presence of the left innominate vein was verified in the superior mediastinum, resecting the thymus if necessary. The fold of Marshal anterior From the Division of Cardiothoracic Surgery, University of Kentucky School of Medicine, Ixxington, Ky. Accepted for publication July 8, 1974. Add.ress reprint requests to Dr. Utley, Division of Cardiothoracic Surgery, University of Kentucky School of Medicine, 800 Rose St., Lexington, Ky. 40504.
VOL.
19, NO.
1,
JANUARY, 1975
101
UI’LEY AND IMOBIN-UDDIN
to the left pulmonary artery was examined for presence of an 1,SVC. Extracoronary venous drainage into the coronary sinus was demonstrated by blood flow from the coronary sinus when the aorta was clamped. Seven patients had absent left innominate vein, persistent LSVC, and extracoronary blood flow to the coronary sinus; 59 had no LSVC, a normal left innominate vein, and no extracoronary coronary sinus flow ( p < 0.001, Fischer’s exact chi-square test).
Comment Although Winter [Z] originally described the relationship of absent left innominate vein and LSVC, the surgical usefulness of this relationship has not been described. By using this sign as evidence of persistent LSVC, we have been better able to plan the operative approach to certain congenital heart lesions. If the persistent LSVC can be identified and controlled with an umbilical tape prior to instituting cardiopulmonary bypass, one may be able to determine if LSVC occlusion produces high venous pressures and venous engorgement of the head. We would cannulate the LSVC through the coronary sinus if venous engorgement occurred. If cannulation of the LSVC is required, the appropriate triple-cannula venous drainage system can be set u p prior to beginning cardiopulmonary bypass. Although the complications of LSVC occlusion are not well documented, we have had no central nervous system dysfunction when this technique was employed. Freed and his colleagues [13 mentioned cerebral complications following LSVC occlusion. They have described techniques of evaluating a persistent LSVC with balloon occlusion preoperatively. Because evidence of persistent LSVC is usually lacking in small infants when cardiac catheterization is performed through the femoral vein, we have found the absent left innominate vein to be a useful sign. We usually place a left central venous pressure catheter when operating on patients in whom occlusion of the LSVC might be necessary. We can thereby determine the safety of LSVC occlusion or the adequacy of drainage.
R ef erences 1. Freed, M. D., Rosenthal, A., and Bernhard, W. F. Balloon occlusion of a
persistent left superior vena cava in the pre-operative evaluation of systemic venous return. J Thorac Cardiouasc Surg 65:835, 1973. 2. Winter, F. S. Persistent left superior vena cava. Angiology 5:90, 1954.
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THE ANNALS OF THORACIC SURGERY
