LEFT RETRO-AORTIC BRACHIOCEPHALIC VEIN WITH AORTO-PULMONARY WINDOW:
SURGICAL DIFFICULTIES IN AN EXTREMELY RARE ENTITY
Javid Raja1, Nishit Santoki1, Vidur
Bansal1, Nitish Jha1, Apeksha
Mittal1, Meenakshi Mandal1, Irshad
R1,
Anand
Kumar Mishra1
Department of Cardiothoracic and Vascular surgery, Post Graduate
Institute of Medical Education and Research, Chandigarh
Corresponding Author
Dr. Nishit Santoki
Department of Cardiothoracic and Vascular Surgery,
Post Graduate Institute of Medical Education and Research,
Chandigarh, India, 160012
Mobile no. +918866246040
Email ID –
nishitpatel009@gmail.com
Keywords: left retro-aortic brachiocephalic vein, aorto-pulmonary window
DISCUSSION –
Left brachiocephalic vein is 6 cm long; it begins behind the sternal end
of the clavicle, anterior to the cervical pleura by union of the left
internal jugular vein and the left subclavian vein. It descends
obliquely to the right, behind the upper half of the manubrium sterni,
up to the sternal end of the first right costal cartilage, uniting here
with right brachiocephalic vein to form SVC. The aortic arch is inferior
to this vein. The left retro-aortic bracheocephalic vein is rare entity
which was first described by Kerschner.(1) Incidence
of left retro-aortic bracheocephalic vein is noted between 0.2 to
1%.(2)
Aorto-pulmonary window is a rare cardiac condition, first described by
Eliotson in 1830(3) with an incidence of 0.2% - 0.3%
of all congenital cardiac lesions.(4,5) Three standard
approaches for surgical closure of aorto-pulmonary window have been
described in literature include: trans-aortic approach, trans-window
approach, trans-pulmonary approach. Trans-window approach is also known
as sandwich repair of aorto-pulmonary window.(6)
The left retro-aortic brachiocephalic vein with tetralogy of fallot and
coarctation of aorta are noted. The left retro-aortic brachiocephalic
vein with aorto-pulmonary window is very rare case and has not been
reported previously. In our case the patient was admitted for AP window
closure after complete pre-operative evaluation. Cardiac computed
tomography reported 2.2cm aorto-pulmonary window with the left
retro-aortic brachiocephalic vein. After obtaining parental consent for
surgery, median sternotomy was performed. Thymus was excised and
pericardium was opened longitudinally. By careful dissection, the left
brachiocephalic vein was identified behind the distal ascending aorta
adjacent to the AP window. Aorta was dissected off the brachiocephalic
vein meticulously. Due to left retro-aortic brachiocephalic vein, aortic
cannulation had to be done more caudally to avoid obstruction of vein.
Aorta was cannulated and clamped without injury to the brachiocephalic
vein. Attention was paid to avoid injury of the brachiocephalic vein
during encircling the SVC for snaring. Aorto-pulmonary window was closed
with PTFE patch through trans-window approach under mild
hypothermia.(6)
Clinical implication of retro-aortic brachiocephalic vein is very
important. More caudal cannulation of SVC is required in left
brachiocephalic vein; but in AP window setting, this is more difficult
as work space for closure of the defect is also required. Injury may
occur to the vein during clamping of aorta. Left retro-aortic
brachiocephalic vein may cause technical difficulty during central
venous line placement through left arm approach.
CONCLUSION-
Being the rarest combination of left retro-aortic brachiocephalic vein
and aorto-pulmonary window, certain things have to be taken care of like
clamping of aorta, SVC cannulation, central vein catheter insertion,
snaring of SVC. Pre-operative CT scan is also important to avoid
intra-operative surprises.
DECLARATIONS-
Conflict of Interest – None
Funding– None
Ethical approval–This manuscript was approved by the departmental
ethics committee
Consent for publication – Informed consent was taken from the child’s
parents
ABBREVIATION-
AP – aorto-pulmonary
CT – computed tomography
PTFE - polytetrafluoroethylene
SVC – superior vena cava
REFRENCES-
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Retroaortic innominate vein with coarctation of the aorta: surgical
repair and embryology review. Ann Thorac Surg. 2003 Mar 1;75(3):1014–6.
3. Elliotson J. Case of malformation of the pulmonary artery and aorta.
Lancet. 1830;1:247-51.
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5. Report of the New England Regional Infant Cardiac Program.
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