Crack in Drainage Cannula During Minimally Invasive ASD Repair Surgery- Troubleshooting of an Unforeseen Complication

Minimally invasive cardiac surgery (MICS) for Atrial Septal Defect (ASD) repair has gained popularity due to its reduced recovery time and improved cosmetic outcomes compared to traditional median sternotomy.[1] It requires peripheral sites of canulation like IJV, femoral vein, and artery for cardiopulmonary bypass (CPB). However, it comes with its own set of unique challenges.[2] We report a case of a cut internal jugular venous (IJV) cannula during ASD repair and the troubleshooting measures employed. Twenty-two-year-old, female patients with ostium secundum Atrial Septal Defect (ASD) with nil comorbid conditions were planned for ASD repair by MICS. With all ASA monitors, the patient was induced with the standard operating protocol. Left radial arterial and left internal jugular venous (IJV) canulation were done for blood pressure monitoring and CVP monitoring respectively. Right IJV was cannulated with brand new 19 Fr venous drainage cannula (Bio-Medicus, Minnesota) and right femoral 21 Fr venous drainage cannula (Edwards Lifesciences, USA) 18 Fr (EOPA, Medtronic, USA)) right femoral arterial cannula for cardiopulmonary bypass. After 15 minutes of initiating CPB, the perfusion team noticed bubbles in the venous cannula and a sudden drop in venous return. Further inspection revealed that the proximal portion of the internal jugular venous cannula was partially cut. Immediate corrective measures to ensure patients’ safety were taken to prevent air embolism, by clamping the IJV canula and Trendelenburg position. Venous drainage was maintained by cannulating SVC separately by the surgeon. The cut tip of the cannula was retrieved by a surgeon from the right atrium. Upon Evaluation [Figures 1 and 2], the cut was localized near the skin entry point and the distal tip of the cut cannula was held in place by enforcement wire preventing it from embolization. The team carefully re-evaluated the cause, which was hypothesized to be related to excessive torque or tightly snugging the cannula at skin level by purse-string sutures. The cannula was also inspected for any manufacturing defects. Given the high risk of air embolism, the anesthesia team immediately implemented measures such as Trendelenburg position and ensuring continuous aspiration of the venous line. A bubble trap and air sensor on the CPB circuit were also monitored closely.Figure 1: Showing cut internal jugular venous cannulaFigure 2: Showing cut internal jugular venous cannulaThe remainder of the surgery proceeded without further complications. The patient was monitored in the ICU postoperatively and extubated after 6 hours. There were no neurological deficits or signs of pulmonary air embolism. The patient had an uneventful recovery and was discharged on postoperative day 5. Cannula-related complications are rare but significant during MICS.[3] A crack in the IJV cannula can be catastrophic, leading to blood loss, air embolism, and even cardiac arrest. The key to managing such an event lies in early detection, immediate isolation of the problem, and establishing alternative venous access to maintain CPB. The decision to switch to SVC cannulation allowed for controlled troubleshooting, ensuring patient safety. This case highlights the importance of careful handling of venous cannula during MICS and the need for a well-prepared surgical team ready to handle unexpected events. Early recognition and prompt intervention are crucial for managing complications like a cut internal jugular venous cannula. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.