ARTICLE IN PRESS doi:10.1510/icvts.2010.260547
Interactive CardioVascular and Thoracic Surgery 12 (2011) 626–627 www.icvts.org
Case report - Cardiac general
Oxidized regenerated cellulose in cardiac computer tomography imaging Thomas Syburraa,*, Dominik Weishauptb, Kirk Gravesa, Michele Genonia Clinic for Cardiac Surgery, City Hospital Triemli, Birmensdorferstrasse 497, CH-8063 Zurich, Switzerland b Institute of Radiology, City Hospital Triemli, Zurich, Switzerland
a
Received 5 November 2010; received in revised form 7 December 2010; accepted 13 December 2010
Abstract Oxidized regenerated cellulose is widely used as a bioabsorbable topical hemostatic agent. Postoperative visualization of this material through routine chest imaging, such as conventional radiography, computer tomography (CT), magnetic resonance imaging as well as sonography, may prove difficult and, to our knowledge, is not described in the literature. We describe a case where the mediastinal packing with Surgicel姠 Nu-Knit姠 after a mitral valve repair procedure led to a delayed obstruction of the superior vena cava, necessitating a rethoracotomy and curettage of the hemostatic material. The hemostatic agent was not prospectively interpreted as the cause of a severe upper inflow restriction, despite repeated imaging. Retrospectively, the hemostatic material as a cause of the upper inflow obstruction could have been identified earlier if its presence would have been known to the radiologist. We strongly recommend that the surgeon inform the radiologist that such materials were used to improve the diagnostic yield of CT interpretation. 䊚 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Cardiac surgery; Hemostasis; Complications; Computer tomography imaging
1. Introduction Bioabsorbable topical hemostatic agents are widely used. Oxidized regenerated cellulose (Surgicel姠 Nu-Knit姠; Johnson and Johnson Medical, Arlington, TX, USA) is one of the most commonly used agents supporting hemostatic efforts. It is a sterile gauze of thrombogenic material which is inert and bioabsorbable w1x. Once saturated with fluid, its volume increases about 20%. The kinetics of the volume increase varies depending on whether the gauze is dressed as a mono-layer or as a multi-layer conglomerate. It may cause acute organ dysfunction if it is packed too tightly, as well as delayed compression by first creating, then trapping a hematoma within its structure w2x. Surgicel姠 Nu-Knit姠 may be left in the surgical bed in certain cases w3x. The most common complication of packing with oxidized cellulose is spinal compression w4x. 2. Case report We report on a case of mediastinal packing with Surgicel姠 Nu-Knit姠 after a mitral valve repair procedure in an 82year-old female patient, which led to a delayed obstruction of the superior vena cava, necessitating a re-thoracotomy on the fourth postoperative day, revision of the situs, and curettage of the hemostatic material. The hemostatic *Corresponding author. Tel.: q41 44 4661186; fax: q41 44 4662745. E-mail address:
[email protected] (T. Syburra). 䊚 2011 Published by European Association for Cardio-Thoracic Surgery
Fig. 1. Unenhanced CT-scan at the first postoperative day in an 86-year-old patient with surgical repair of the mitral valve. An air-containing ovular mass is visible immediately at the level of the superior vena cava (arrows). In addition, a central venous catheter as well as right-sided pleural drainage are visible. CT, computed tomography.
material was not obstructive on the first unenhanced computer tomography (CT)-scan (Fig. 1, arrows), which was performed in the first postoperative night due to progressive pulmonary failure. There was no evidence of superior vena cava compression at the time of the first CT-scan. At the time of the clinical onset of superior inflow obstruction, transesophageal echocardiography (TEE) as well as a second contrast-enhanced CT-scan (Fig. 2a–c) were performed.
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Fig. 2. Contrast-enhanced CT-scans of the same patient as in Fig. 1 that were performed at the fourth postoperative day when the patient presented with upper venous inflow obstruction. (a) Contrast-enhanced transaxial CT of the chest obtained at the level of the right pulmonary vein demonstrates a patent superior vena cava (arrow) with an intraluminal catheter. (b, c) Transaxial contrast-enhanced CT image obtained 2 cm below the image a (b) and coronal reformation (c) demonstrate an oval shaped mass containing air bubbles (arrows) is visible leading to compression the superior vena cava. CT, computed tomography.
w1x Masova L, Rysava J, Krizova P, Suttnar J, Salaj P, Dyr JE, Homola J, Dostalek J, Myska K, Pecka M. Hemostyptic effect of oxidized cellulose on blood platelets. Sb Lek 2003;104:231–236. w2x Patane F, Zingarelli E, Verzini A, di Summa M. Complication due to excessive use of Surgicel. Eur J Cardiothorac Surg 2001;20:1034. w3x Pierce A, Wilson D, Wiebkin O. Surgicel: macrophage processing of the fibrous component. Int J Oral Maxillofac Surg 1987;16:338–345. w4x Brodbelt AR, Miles JB, Foy PM, Broome JC. Intraspinal oxidised cellulose (Surgicel) causing delayed paraplegia after thoracotomy – a report of three cases. Ann R Coll Surg Engl 2002;84:97–99. w5x Oto A, Remer EM, O’Malley CM, Tkach JA, Gill IS. MR characteristics of oxidized cellulose (Surgicel). Am J Roentgenol 1999;172:1481–1484. w6x Henry MC, Tashjian DB, Kasowski H, Duncan C, Moss RL. Postoperative paraplegia secondary to the use of oxidized cellulose (Surgicel). J Pediatr Surg 2005;40:E9–E11. w7x Arat YO, Dorotheo EU, Tang RA, Boniuk M, Schiffman JS. Compressive optic neuropathy after use of oxidized regenerated cellulose in orbital surgery: review of complications, prophylaxis, and treatment. Ophthalmology 2006;113:333–337. w8x Young ST, Paulson EK, McCann RL, Baker ME. Appearance of oxidized cellulose (Surgicel) on postoperative CT-scans: similarity to postoperative abscess. Am J Roentgenol 1993;160:275–277.
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Surgicel姠 Nu-Knit姠 increases in volume when in contact with fluid. When used as a multi-layer conglomerate, this volume increase may be delayed for many days. A CT-scan as well as a TEE-study identified an obstruction of the superior caval vein, but missed the cause of the compression of the superior caval vein: the Surgicel姠 Nu-Knit姠 conglomerate. Retrospectively, the radiologist could have made the identification easily if the surgeon had provided information on its use in the operation and its location. We strongly recommend that the surgeon communicate the use of such materials, particularly when used as a conglomerate, to the radiologist or cardiologist to allow for an accurate interpretation of the imaging w2, 4–8x. This information may lead to an earlier and more precise diagnosis.
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Although compression of the superior caval vein was well visualized, its cause was prospectively not properly determined. The air-containing mass, which led to compression of the superior caval vein, proved intraoperatively to correspond to the Surgicel姠 Nu-Knit姠 conglomerate, which made a delayed volume expansion during the four days after the initial packing. After the re-thoracotomy, the patient could be transferred to the ward on the 21st postoperative day and was discharged from the hospital on the 45th postoperative day in good condition.
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