Ann Thorac Surg 1998;65:263
© 1998 The Society of Thoracic Surgeons
Case Reports
Resection of a Pulmonary Malignancy Invading the Intrapericardial Inferior Vena Cava
John R. Roberts, MD,
Patti S. Abbott, PA,
W. Roy Smythe, MD,
Joseph E. Bavaria, MD
Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Accepted for publication September 5, 1997.
Dr Roberts, Department of Cardiac and Thoracic Surgery, Vanderbilt University School of Medicine, 2986 The Vanderbilt Clinic, Nashville, TN 37232-5734.
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Abstract
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Resection of extensive lung cancers invading thoracic vascular structures (T4 lesions) can yield long-term survival provided the margins and nodes are free of tumor. We report the resection of the suprahepatic inferior vena cava for direct tumor involvement by a pulmonary malignancy. The resection was performed without bypass, and the cava was subsequently reconstructed with a 22-mm-diameter Dacron graft. Patency was documented on postoperative magnetic resonance angiograms. The patient was discharged home on postoperative day 10 without complications and remains well 8 months after the operation. Potentially curative resections and reconstructions of suprahepatic inferior vena cava involved with pulmonary malignancies are possible and can be done without cardiopulmonary bypass.
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Introduction
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Pulmonary malignancies may invade mediastinal structures (superior vena cava, main pulmonary vessels, carina, pericardium, and myocardium), making their resection difficult and the likelihood of cure smaller. Nonetheless, resections of these structures, especially of the superior vena cava, can be performed with subsequent long-term survival [1][2][3][4]. Superior vena caval reconstruction can be reliably done with either polytetrafluoroethylene or spiral saphenous vein grafts [1][5], although the choice of material to reconstruct the inferior vena cava (IVC) is less clear [6]. Further, whereas clamping of the infrahepatic IVC can be done without danger, operating on the suprahepatic IVC may require cardiopulmonary bypass [5][7][8]. We report resection of a pulmonary malignancy invading the suprahepatic IVC with primary reconstruction without cardiopulmonary bypass.
A 55-year-old man had undergone an laryngectomy 2 years ago for a squamous cell carcinoma. Six months later a partial glossectomy was done for recurrence of tumor. Multiple endoscopies had since demonstrated no new recurrence. Follow-up chest roentgenograms demonstrated a right lower lobe mass. Chest computed tomographic scan demonstrated a large mass in the right lower lobe abutting the pericardium and encircling the inferior pulmonary vein. The lesion appeared to be invading the diaphragm but was free of the IVC. Because of an adrenal lesion a magnetic resonance imaging scan was obtained. The adrenal lesion was interpreted as a benign adenoma and the IVC as compressed but not invaded (Fig 1Fig 2).
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Preoperative chest magnetic resonance image just superior to the diaphragm demonstrating compression but not occlusion or invasion of the inferior vena cava (outlined by arrows).
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At mediastinoscopy benign lymph nodes were found at levels 4R, 4L, and 7. At exploration a large mass invaded the pericardium at the inferior pulmonary vein and involved the diaphragm. Opening the pericardium revealed that the tumor did not invade the heart but did invade the IVC. The pulmonary artery was divided in the fissure and the inferior pulmonary vein was divided at the left atrium with endoscopic vascular staplers. The bronchus to the right lower lobe was divided. The lesion came cleanly off the posterior mediastinum without evidence of invasion into the esophagus or the spine.
The diaphragm was divided to give a 2-cm margin. Multiple firings of vascular staplers were used to divide the IVC just inferior to the myocardium and just above the junction of the hepatic veins with the IVC. The patient’s blood pressure fell to a systolic level of approximately 70 mm Hg at this point, requiring renal-dose dopamine and approximately 3 L of crystalloid to maintain appropriate blood pressure and urine output. Over the half hour between division and completion of reconstruction the liver became tense and ascites and oliguria developed. The IVC was reconstructed with a 22-mm-diameter Dacron graft from the suprahepatic IVC to the right atrium. After the graft was opened, filling of the right heart and elevation of the mean systemic pressure from 70 to 120 mm Hg was seen. Over the course of the next 10 minutes his urine output increased to 100 mL per each 15 minutes of the next hour. The bronchial, vascular, and diaphragmatic margins were all negative on frozen and permanent section.
The patient tolerated the remaining procedure without difficulty. He was extubated early the next morning and diuresed over the next several days. His creatinine level remained normal for the entire 10-day hospital stay. The final pathologic diagnosis was a squamous cell carcinoma, with all margins and nodes negative for tumor; the tumor was staged T4 N0. Although the lesion was a squamous cancer, we could not ascertain whether it was likely to be a new primary tumor or a metastasis. Postoperative magnetic resonance imaging angiography at 10 days demonstrated the graft to be patent. He remains well 8 months after resection without evidence of disease.
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Comment
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Resections of major thoracic venous structures involved by pulmonary malignancies are technically feasible. At issue are the material used for reconstruction, the need for cardiopulmonary bypass, and whether such resections offer any chance of long-term survival.
Extensive experience with replacement of the superior vena cava with either spiral saphenous vein graft [9] or polytetrafluoroethylene [1] has yielded high patency rates. Experience with IVC replacement is less extensive, but the available clinical data indicate that polytetrafluoroethylene may be superior to saphenous vein for large venous replacement in the abdomen [5][6]. Dacron [5] and pericardium [8] have also been used clinically with good results. Gloviczki and associates [10] studied the experimental replacement of the infrarenal IVC in dogs, however, and found better (67% versus 25%) patency with spiral saphenous vein graft than polytetrafluoroethylene; patency of both types of conduit was improved with distal arteriovenous fistulas. Further, patency of both conduits was 100% while subjects were maintained on antiplatelet therapy.
Replacement of the superior vena cava can easily be done without cardiopulmonary bypass, although long clamp times may yield facial edema [1][4][9]. In general, replacement of the suprahepatic IVC has been done with the support of some sort of cardiopulmonary bypass [5][8], though retrohepatic cavoatrial bypass for patients with Budd-Chiari syndrome has been done without bypass [6]. Although some hemodynamic instability developed in our patient, this was managed easily with volume support and low-dose pressors. His postprocedure course was no more complicated by his intraoperative fluid management than it would have been with bypass.
Because this patient’s IVC was severely compressed and appeared to have little flow through it, we elected to resect it without shunting or bypass. Nonetheless, temporary occlusion of the suprahepatic IVC without drainage, either partial or complete cardiopulmonary bypass or temporary shunting, is not tolerated in most patients and was barely tolerated in this patient. Temporary shunting via cannulas passed from the right atrial appendage into the infrahepatic IVC has been extensively used in hepatic trauma and could have been used in this patient [11]. Similarly, femoral venous shunting into the right atrium would have allowed for safe long-term clamping of the suprahepatic IVC. Finally, partial or complete cardiopulmonary bypass, with or without hypothermia, has been used for patients with membranous obstruction of the IVC [8], in acute traumatic obstruction of the IVC [12], and in resection of a portion of the infrahepatic IVC involved with renal carcinoma [7].
Although rare, long-term survival after resection of the superior vena cava involved with malignancy is possible. Dartevelle and colleagues [1] reported an overall survival rate of 48% at 5 years in patients who had undergone superior vena caval resection in conjunction with resection of pulmonary or mediastinal malignancies, although there were no survivors among patients with positive mediastinal nodes. Others have published case reports of 5-year survival [2][3][4]. Resection of the IVC can be done safely, with or without cardiopulmonary bypass, and may be appropriate when mediastinal nodes are negative.
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References
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Abstract
Introduction
