European Journal of Echocardiography 2005 6(5):385-387; doi:10.1016/j.euje.2004.12.005
Copyright © 2005, The European Society of Cardiology
Diagnosis of perigraft seroma formation by use of echocardiography after modified Blalock–Taussig shunt
Omer Faruk Dogana,*,
Umit Dumana,
Tevfik Karagozb,
Suheyla Ozkutlub and
Unsal Ersoya
aDepartment of Cardiovascular Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
bDepartment of Pediatric Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
Received 15 September 2004; .
ofdogan{at}hacettepe.edu.tr
* Corresponding author. Birlik Mahallesi, 59, Sokak 9/1, Çankaya, 06670 Ankara, Turkey. Tel.: +90 312 495 68 98; fax: +90 312 311 04 94.
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Abstract
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Perigraft seroma is a collection of non-secretory fibrous pseudomembrane
surrounding a vascular graft, which is a collection of clear,
sterile fluid. Thoracal computed tomography, Magnetic Resonance
Imaging, and thoracal ultrasonography have been proposed for
diagnosis of this pathology. A consecutive modified Blalock–Taussig
(m-BT) shunt complicated by perigraft seroma formation, which
is diagnosed using a Doppler ultrasonography (US), is presented
here.
Keywords: Perigraft seroma; Graft compression; Echocardiography
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Case report
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A 10-month-old female infant was referred to our clinic with
cyanosis and dispnea. Echocardiographic study revealed the presence
of tetralogy of Fallot and pulmonary atresia. The left mBT shunt
was constructed with a 4mm polytetrafluoroethylene (PTFE) graft.
Continuously intravenous heparin was given after surgery (2mg/kg/day)
for two days postoperatively. Following the operation, cyanosis
disappeared and continuous murmur was heard on the second intercostal
space. However, her oxygen saturation decreased and respiratory
distress began within six days after surgery. The infant was
immediately entubated. Chest X-ray showed a large and well demarcated
left superior mediastinal mass, pleural effusion, and a marked
tracheal displacement to the contralateral side (
Fig. 1). The
echocardiographic study revealed a large cystic formation at
the arcus aorta and encircling of the functioning PTFE graft
(
Fig. 2). A continuous flow across the shunt was found, and
an 80mmHg systolic gradient was recorded from PTFE graft.
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Figure 2 Subcostal transthoracic echocardiography is demonstrating a large cystic formation at the arcus aorta and encircling the functioning PTFE graft (a 80mmHg gradient was obtained across the synthetic material). Tr-Ao: transverse aorta, Ao: Aorta, PA: Pulmonary artery, B–TS: Functioning B–T shunt in color Doppler, LV: Left Ventricle. Arrows are showing the cystic formation.
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Chest X-ray showed the enlargement of the mass and blood gas
oxygen saturation was decreased and the patient could not be
extubated after two days from entubation, and because of progressive
decrement of the arterial oxygen saturation and developing signs
of respiratory distress, she underwent urgent re-thoracotomy.
At the operation, dimension of the mediastinal mass was found
as 4
x5cm (
Fig. 3). Fluid was aspirated and the seroma was evacuated.
There was a low degree of kinking and anterior angulation of
the PTFE graft; however, thrill was palpable. As the seroma
was removed, kinking and angulation of the graft was lost and
oxygen saturation increased from 40–50% to 95% immediately.
Postoperative course of the patient was uneventful, and she
was extubated on postoperative second day. She was discharged
from hospital on the fifth day without evidence. The patient
was symptom free six months after operation, and there was no
evidence of seroma formation in the serial echocardiographic
examinations.
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Figure 3 Surgical appearance of the seroma formation and anterior angulation of the PTFE graft shown in this figure. Arrow A is showing an angulated and functioning m-BT shunt due to posterior compression by a large seroma formation.
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Discussion
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Since 1976, polytetrafluoroethylene graft (Gore-Tex
®) was
used for modified Blalock–Taussig shunt in congenital
cardiac disease.
1 In the literature, several complications of
the m-BT shunts such as thrombosis, aneurysm formation, hematoma
and perigraft seroma were reported.
2,3 The incidence has been
reported as 6.8–9.5% following peripheral graft material,
4 and 18.8% ratio has been reported after m-BT shunt procedure.
2 A perigraft seroma is defined as a sterile collection of fluid
in a non-secretory wall surrounding a shunt. However, the cause
of seroma formation is not clear yet. Generally, the most widely
accepted theory is handling of the PTFE graft causes leakage
because of a change from a hydrophobic state into a hydrophilic
one.
5 Optimal therapeutic strategies are not clear yet. However,
the removal of the mass is obtained cure in 72% of symptomatic
patients. Number of imaging techniques were defined for diagnosis
of perigraft seroma such as computed tomography (CT),
6,7 Magnetic
Resonance Imaging
6,8 (MRI) and thoracal ultrasonography.
9 Therefore,
a negative result on sonography should lead to further investigation
with CT or MRI.
The Doppler US has an advantage over the other imaging techniques because it can detect shunt blood flow, and no radiation exposure in critically ill infants. In addition, US with Doppler require no patient transportation. A positive finding on sonography means that no further radiologic investigations are indicated.
In summary, the chest radiography shows the first sign of the seroma after m-BT shunt, using thoracic sonography, it is also possible to demonstrate the perigraft seroma and the function of mB-T shunt. Thoracal CT or MRI may be performed in revealing perigraft seromas. When the seroma was found in the critically cases, US has an advantage over CT and MRI because of its portability and capability for bedside use. We recommend the use of US with Doppler as a first diagnostic tool because of information about m-BT shunt functioning and infants cardiac functions at the same time. When infant cannot be extubated and they have no evidence of airway infection, although they have a functioning m-BT shunt, perigraft seroma formation should be kept in mind.
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References
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- Gazzaniga A.B., Elliot M.P., Sperling D.R., Dietrick W.R., Eiseman J.T., McRae D.M., et al. Microporous expanded PTFE arterial prostesis for construction of aorticopulmonary shunts: experimental and clinical results. Ann Thorac Surg (1976) 21:322–327.[Abstract]
- LeBlanch J., Albus R., Williams W.G., Moes C.A.F., Wilson G., Freedom R.M., et al. Serous fluid leakage: a complication following the modified Blalock–Taussig shunt. J Thorac Cardiovasc Surg (1984) 88:259–262.[Abstract]
- Boulden T.F., Tonkin I.L.D., Burton E.M., Siedel F.G., Magill H.L., Hanna S.L., et al. Mycotic pseudoaneursym and thrombosis of modified left Blalock–Taussig shunt. Radiographics (1990) 10:119–121.[Web of Science][Medline]
- Scherer G., Roeren T., Paetz B., Hupp T., Kauffmann G.W. Sonographische befunde bei perigraftreaktionen nach operativer implantation von Gefäβprothesen. Rofo (1995) 162:46–50.[Medline]
- McKay R. Securing of security: the polytetrafluoroethylene leak. Cardiol Young (1995) 5:6.
- Ruud S.A., McAdams H.P., Cohen A.J., Midgley F.M. Mediastinal perigraft seroma: CT and MR imaging. J Thorac Imaging (1994) 9:120–122.[Medline]
- van Rijn R.R., Berger R.M.F., Lequin M.H., Robben S.G.F. Development of perigraft seroma around modified Blalock–Taussig shunts: imaging evaluation. Am J Roentgenol (2002) 178:629–633.[Abstract/Free Full Text]
- Duerinck A., Atkinson D., Klitzner T.S., Perloff J., Drinkwater D., i Laks H. MR imaging of surgical complications of systemic-to-pulmonary artery shunts. Magn Reson Imaging (1996) 14:1099–1105.[CrossRef][Web of Science][Medline]
- Ozkutlu S., Ozbarlas N., Demircin M. Perigraft seroma diagnosed by echocardiography a complication following Blalock–Taussig shunt. Int J Cardiol (1992) 36:244–246.[CrossRef][Web of Science][Medline]
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Abstract
Case report