Successful Post-Operative Bypass Graft Procedure with PTFE

By Dr. Vishal Dhir in Metro Heart Institute with Multispecialty, Faridabad

The patient had a functioning left brachiocephalic arteriovenous (AV) fistula. They presented with massive bilateral pleural effusion, pericardial effusion, and signs of cardiac tamponade. A pigtail catheter was inserted into the pericardial cavity using color Doppler. Thrombosis was observed in the right internal jugular vein, subclavian vein, innominate vein, Segment of superior vena cava between innominate vein and right atrium was patent.

CT venography revealed patency in the left internal jugular vein and left subclavian vein, but the innominate vein was thrombosed. Attempted stenting of the innominate vein from the left cephalic vein was unsuccessful, leading to the abandonment of the procedure.

Surgical intervention was planned, involving graft placement from the left subclavian vein/ internal jugular vein junction to the right atrial appendage. The patient’s significant swelling in the chest wall and neck, along with dilated venous collaterals, posed challenges during the approach.

A midline sternotomy was performed to expose and dissect the innominate vein under the left chest wall until the left subclavian vein function. The innominate vein was transected just before the internal jugular vein/ subclavian vein junction. Hegar dilators were passed into the subclavian vein to ensure adequate patency. An 8mm diameter PTFE graft was anastomosed between the left internal jugular vein/ subclavian vein junction and the right atrial appendage. Both pleural cavities were opened, and pleural fluid was drained.

Following the surgery, the patient had an uneventful recovery, with a significant decrease in swelling of the face, neck, and chest wall.