Superior vena cava syndrome caused by a swollen absorbable haemostat after repair of ischaemic mitral regurgitation

Haemostatic agents are quite useful in almost all surgeries. An absorbable haemostat is also effective in controlling oozing of suture lines or stripped surfaces. Surgicel (Ethicon, North Ryde, NSW, Australia), an absorbable sheet of oxidized cellulose polyanhydroglucuronic acid polymer, has been used in numerous cardiovascular surgeries; however, recent reports have revealed that Surgicel can disturb organ function in several contexts [1–4]. We report a case of superior vena cava (SVC) syndrome due to compression by an haematoma formed around swollen Surgicel.

Surgicel, an absorbable sheet of oxidized cellulose polyanhydroglucuronic acid polymer, has been used in many surgical fields. Surgicel is used at surgical oozing sites, physically promoting coagulation and producing an artificial clot [1, 2].

Although Surgicel is often left in surgical sites for effective postoperative haemostasis, previous reports have revealed that a swollen Surgicel can compress and obstruct the function of neighbouring organs. Dogan et al. reported a case of paraplegia following left-sided thoracotomy, suggesting that Surgicel may migrate into the vertebral canal and produce haematomas that result in spinal cord compression [1]. Another report has described the complications associated with Surgicel-produced haematomas, including hemiparesis after trigeminal decompression [2].

As in other surgical specialties, several cases of Surgicel-related complications in cardiovascular surgery have been reported [3–5]. A recent report showed that Surgicel caused severe stenosis of a pulmonary homograft when Surgicel was placed around the suture lines of the pulmonary artery [4]. However, no cases of postoperative SVC syndrome caused by Surgicel have been reported.

In most cases, SVC syndrome is associated with lung cancer, other tumours, SVC catheters, and venous thrombosis, whereas postoperative SVC syndrome in cardiovascular surgery is rare. In our case, the patient developed SVC syndrome suddenly on postoperative day two. Although her international normalized ratio 1.4 and activated partial thromboplastin time 38.2 seconds were within nornal limits, her clinical course and images on CT and angiography suggested the possibility of catheter-associated SVC thrombosis or stenosis caused by CPB cannulation; however, the emergent redo surgery revealed that the haematoma in the posterior side of the SVC was compressing the SVC externally and swollen Surgicel had enhanced compression by the haematoma. This was a finding that is clearly different from compression secondary to Surgicel granuloma formation occurring at a later stage of surgery. Furthermore, in spite of no evidence of the injury of the right pulmonary artery, a very small amount of bleeding had continued from the sternum. In the elderly, the density of the sternum is significantly low, which may promote bleeding from the bone marrow postoperatively, thus resulting in development of “Surgiceloma” [2].

Surgicel is quite useful in many haemostatic situations, whereas the Surgicel left in surgical sites can produce a postoperative “Surgiceloma” that can be an external compressor, particularly in lower pressure systems or organs such as atriums and veins. Our experience may impress upon surgeons the importance of appropriate use of haemostatic agents.

Surgeons should consider the possibility of postoperative compression by haemostatic agents swollen with blood, specially in lower pressure systems or organs.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.