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-
1. Kerschner L. Zur Morphologie der Vena Cava Inferior. Anat Anz 1888;3:808–823.
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3. Elliotson J. Case of malformation of the pulmonary artery and aorta. Lancet. 1830;1:247-51.
4. Kutsche LM, Van Mierop LH. Anatomy and pathogenesis of aorticopulmonary septal defect. Am J Cardiol. 1987 Feb 15;59(5):443–7.
5. Report of the New England Regional Infant Cardiac Program. Pediatrics. 1980 Feb;65(2 Pt 2):375–461.
6. Johansson L, Michaelson M, Westerholm CJ, Aberg T. Aortopulmonarywindow: a new operative approach. Ann Thorac Surg 1978;25:564–567.