Pneumothorax following subclavian venipuncture is a well-known risk. Less well recognized is the potential for life-threatening bilateral pneumothoraces occurring at the time of subclavian vein catheterization in patients who have previously undergone median sternotomy. Inadvertent bilateral pleural entry at the time of sternotomy may result in a common pleural space which subsequently places the patient in special jeopardy when the complication of pneumothorax occurs. This report documents the successful management of this important sequence of complications associated with now widely applied therapeutic interventions

Johnson, Jr., G

Khouri, R.K.

Murray, G.F.

Schorlemmer, G.R.

English

Carolina Digital Repository

Bilateral Pneumothoraces Secondary tolatrogenic Buffalo ChestAn Unusual Complication of Median Sternotomy andSubclavian Vein CatheterizationGILBERT R. SCHORLEMMER, M.D., ROGER K. KHOURI,GEORGE JOHNSON, JR., M.D.Pneumothorax following subclavian venipuncture is a well-knownrisk. Less well recognized is the potential for life-threateningbilateral pneumothoraces occurring at the time of subclavianvein catheterization in patients who have previously undergonemedian sternotomy. Inadvertent bilateral pleural entry at thetime of sternotomy may result in a common pleural space whichsubsequently places the patient in special jeopardy when thecomplication of pneumothorax occurs. This report documentsthe successful management of this important sequence of com-plications associated with now widely applied therapeutic in-terventions.IITITH THE RAPID PROGRESS in techniques of cardio-V plegia and anesthesia, coronary artery bypassgrafting has become commonplace. The normal approachvia a median sternotomy places both pleural cavities atrisk for entry. Fusion of bilateral pleural rents may resultin a common pleural space, similar to that which is some-times found in the North American buffalo (PersonalCommunication, Kenneth Throlson, D.V.M., NewRockford, ND). Such an acquired atavism may be a sourceof life-threatening complications, as in the case reported.Case ReportA 68-year-old white man presented with lower extremity rest painand an ischemic ulcer of the right leg. Preoperative evaluation revealedClass IV angina, and coronary angiography demonstrated three vesseldisease. Coronary artery bypass grafting was performed through a mediansternotomy. During the procedure both pleural cavities were openedM.D., GORDON F. MURRAY, M.D.,From the Divisions of Cardiothoracic and Vascular Surgeryand the Department of Surgery, University of North CarolinaSchool of Medicine, Chapel Hill, North Carolinaand latex mediastinal tubes were inserted through the pleural rents inorder to maintain full expansion ofthe lungs. The patient enjoyed stablecardiopulmonary function and the chest tubes were removed after 24hours. Because of persistent leg rest pain and nonhealing saphenousvein donor sites he underwent successive revascularization ofboth lowerextremities. After surgery his recovery was prolonged. Because of mal-nutrition, central venous access for hyperalimentation was obtained viaa right infraclavicular subclavian venipuncture. Insertion was complicatedby two unsuccessful passes on the right side. Shortly thereafter, thepatient experienced marked respiratory distress. A chest roentgenogramrevealed large bilateral pneumothoraces (Fig. 1). A tube thoracostomywas performed in the right fifth intercostal space and the patient's symp-toms resolved immediately. Repeat chest roentgenography revealed anunusual position of the thoracostomy tube as it crossed the midline withits tip coming to rest in the superior portion of the left chest (Fig. 2).Lateral films revealed the tube to pass through the anterior mediastinum(Fig. 3). The tube was withdrawn into the right chest and eventuallyremoved after full expansion of both lungs was maintained. Hyperali-mentation was continued until the catabolic state was reversed. On 4-month follow-up, the patient was gaining weight with complete reliefof his angina, and was ambulatory with well-healed leg wounds.CommentThe frequency with which central venous catheteriza-tion has been used for cardiovascular monitoring or in-travenous hyperalimentation has increased drastically inrecent years. Since its introduction by Aubaniac in 1952,'percutaneous infraclavicular subclavian vein catheteriza-tion has gained popularity as a safe, reliable, and practicalaccess to the central venous circulation.24 Other authors,however, have drawn attention to its complications.7'8372Reprint requests: Roger K. Khouri, M.D., Department of Surgery,School of Medicine, University of North Carolina, Burnett WomackBuilding 229H, Chapel Hill, NC 27514.Submitted for publication: August 29, 1983.IATROGENIC BUFFALO CHESTFIG. 1. Bilateral pneumothoraces (arrows) are noted following right sub-clavian vein catheterization.Pneumothorax is the most common noninfectious com-plication of subclavian venous puncture and occurs in0.6% to 7.5% of catheter placement attempts.4 Bilateralpneumothoraces have been reported but have always beenassociated with bilateral catheterization attempts.9In this patient the prior median sternotomy associatedwith coronary artery bypass grafting resulted in bilateralanterior pleural rents which subsequently sealed to forma pleuro-pleural canal in the anterior mediastinum. Theresult was the formation of a single pleural space com-parable to that found on occasion in the North Americanbuffalo. (Personal communication, Kenneth Throlson,D.V.M.) This unique anatomy was apparently wellknown, if not understood, by the North American Indian,who recognized that a single chest wound in this speciesfrequently resulted in rapid death (presumably from sud-den bilateral pneumothoraces). Bilateral pneumothoracesresulting from unilateral chest trauma have also beenrecognized in the horse, in whom fenestrations in theventral aspect ofthe caudal mediastinal pleura have beennoted to connect the pleural spaces.'0 Such openings havealso been noted in sheep, mules, and some carnivores.'0In our patient the unsuccessful subclavian venous cath-eterization attempts apparently disrupted the right apicalpleura, generating bilateral pneumothoraces in the com-mon pleural cavity ofthe patient's iatrogenic buffalo chest.Inadvertent bilateral pleural entry at the time ofmediansternotomy is unusual, but does occur. The incidence ofpersistent pleuro-pleural connection following such injuryis, of course, unknown. Nevertheless, physician awarenessof the possibility of a common pleural cavity in a patientiFIG. 2. Subsequent tube thoracostomy resulted in a transmediastinaltube location. Both lungs are fully expanded.FIG. 3. The lateral chest roentgenogram demonstrates that the tubepasses through the anterior mediastinum, presumably through a pleuro-pleural canal resulting from the previous median sternotomy.373Vol. 199 * No. 3!.374 SCHORLEMMER AND OTHERS Ann. Surg. March 1984who has undergone sternotomy gains importance wheninvasive therapeutic procedures such as subclavian veincatheterization are undertaken. Recognition ofthe greaterjeopardy for severe respiratory distress associated withbilateral pneumothoraces should alert the physician tomake adequate preparation for closed tube thoracostomy.A single chest tube should be sufficient for treatment, asdemonstrated in the current patient. Finally, when bothpleural spaces are noted to be violated at the time ofmedian sternotomy, consideration should be given to su-ture closure of one of the pleural cavities to prevent uni-fication of the spaces and subsequent iatrogenic buffalochest.AcknowledgmentsOur sincere thanks to Kenneth Throlson, D.V.M., ofNew Rockford,North Dakota, and Edgar Smallwood, D.V.M., School of VeterinaryMedicine, North Carolina State University, Raleigh, North Carolina,for their assistance in the comparative anatomy sections of this text.References1. Aubaniac R. L'injection intraveineuse sans claviculaire: advantageset technique. Presse Medicale 1952; 60:1456.2. Merk EA, Rush BF Jr. Emergency subclavian vein catheterizationand intravenous hyperalimentation. Am J Surg 1975; 129:266-268.3. Wilson JN, Grow JB, Demong CV, et al. Central venous pressurein optimal blood volume maintenance. Arch Surg 1962; 85:563-577.4. Bernard RW, Stahl WM. Subclavian vein catheterization: a pro-spective study. I. Non-infectious complications. Ann Surg 1971;173: 184-190.5. Keeri-Szanto M. The subclavian vein, a constant and convenientintravenous injection site. Arch Surg 1956; 72:179-181.6. Nehme AE. Swan-Ganz catheters: comparison of insertion tech-niques. Arch Surg 1980; 115:1194-1196.7. Johnson CL, Lazarchick J, Lynn HB. Subclavian venipuncture:preventable complications. Mayo Clin Proc 1970; 45:712-719.8. Smith BE, Modell JH, Gaub ML, Moya F. Complications of sub-clavian vein catheterization. Arch Surg 1965; 90:228-229.9. Maggs PR, Schwaber JR. Fatal bilateral pneumothoraces compli-cating subclavian vein catheterization. Chest 1977; 70:552-553.10. Schummer A, Nickel R, Sack WO. Body cavities. In The Visceraof the Domestic Mammals, 2nd ed. New York: Springer-Verlag,1979; 6.

Bilateral pneumothoraces secondary to latrogenic buffalo chest. An unusual complication of median sternotomy and subclavian vein catheterization.

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Bilateral pneumothoraces secondary to latrogenic buffalo chest. An unusual complication of median sternotomy and subclavian vein catheterization.

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