Management of a small bowel transplant with complicated central venous access in a patient with asymptomatic superior and inferior vena cava obstruction

During the past few years, small bowel transplantation (SBT) has become a realistic alternative for patients with irreversible intestinal failure who have or will develop severe complications from total parenteral nutrition (TPN). Transplantation can be associated with large fluid shifts and massive blood loss necessitating rapid infusions of large quantities of crystalloid and/or blood products. Invasive monitoring and large-bore venous access are necessary in order to manage these patients intraoperatively. Because patients with irreversible intestinal failure are often managed with total parenteral nutrition via a central venous catheter, thrombotic intraluminal obstruction of major vessels may develop over time. Additionally, this may lead to superior vena cava (SVC) syndrome as well as challenging problems with vascular access. We present a 34-year-old woman with a past medical history for long-standing Crohn's disease with multiple small bowel resections and short gut syndrome who presented for an SBT. The patient had a long history of TPN use, complicated by SVC syndrome and inferior vena cava (IVC) obstruction. She was presently asymptomatic from her SVC obstruction. Central venous access was obtained by an interventional radiologist. A 7-French double-lumen Hickman minicatheter was placed in the left femoral vein with the tip of the catheter positioned just distal to the IVC narrowing. A left radial 20-gauge arterial line was placed for hemodynamic monitoring and frequent blood sampling. The patient's left and right dorsal-saphenous veins were cannulated with 16-guage catheters and adequate flow was observed. Lower extremity pressure was measured via the Hickman catheter in the left femoral vein. A multiplane transesophageal echo was used to assess ventricular volume. The options and intraoperative management of such patients are discussed.