Letter to the Editor

DOI: 10.19102/icrm.2012.030902

Scott Lick, MD, FACS

Please allow this commentary to serve as a follow up regarding the recently published manuscript within The Journal of Innovations in Cardiac Rhythm Management by Rahaby and Niazi, describing placement of a supplemental defibrillation coil in the azygous vein (Azygous Vein Coil: Bailout Strategy for High Defibrillation Thresholds, 3(2012), 905–10).

I would like to add a word of caution to this manuscript. Occasionally I am requested to the operating room stat due to iatrogenic perforation of the azygous vein during placement of large left subclavian catheters (ex. dialysis lines, tunnel catheters, etc). The azygous lies quite posterior in the chest, and in the supine patient, acts similar to the oil pan drain plug in a car: with a large tear, quick in-sanguination into the right chest ensues.

This problem is only made worse with placement of a chest tube – which merely converts in-sanguination to ex-sanguination. Therefore, successful treatment of an azygous tear (which could conceivably occur if this procedure becomes more widespread) is as follows:

1)	Remove the offending catheter or sheath.
2)	Intubate the patient and use high levels of positive-end expiratory pressure (PEEP), which provides sustained contact between the visceral lung pleura/parietal pleura and the vein tear throughout the respiratory cycle. This should effectively patch the hole.
3)	If possible, roll the OR bed left side down (or turn the patient left-side down), minimizing venous pressure in this right-sided vein.

Delayed drainage of pleural blood can then be selectively applied, if at all necessary, at a later time after the hole has sealed.

As a thoracic surgeon, my non-thoracic surgical colleagues are somewhat surprised at this non-surgical management strategy. In my experience, this strategy has proven more effective than chest tube drainage and also open attempts at repair of this life-threatening iatrogenic complication.

Scott Lick, MD, FACS
slick@utmb.edu
Professor of Surgery (Cardiothoracic)
University of Texas Medical Branch
Galveston, TX