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Ann Thorac Surg 1998;65:1836-1837
© 1998 The Society of Thoracic Surgeons

Correspondence

Homograft and SVC Syndrome

J. Rodrigo Oyarzun, MDa, John R. McCormick, MDa

a Section of Cardiothoracic Surgery, UMDNJ/New Jersey Medical School, 185 S Orange Ave, G595, University Heights, Newark, NJ 07103-2714, USA

To the Editor

We read with great interest the recent article by Ohri and associates entitled "Homograft as a Conduit for Superior Vena Cava Syndrome" [1]. In view of the promising results of homografts in the surgical treatment of aortic valve disease, it is not a surprise that the superiority of these biological tissues over alternative vascular conduits is being recognized more often. The unique properties of cryopreserved homografts in terms of low immunogenicity and thrombogenicity certainly represent an advantage over prosthetic material [2]. Even further, the smooth endothelial lining and the absence of a suture line may improve the modest patency rates obtained with the traditional spiral vein graft in the management of superior vena cava (SVC) syndrome [3].

Obstruction of the SVC secondary to benign or malignant disease is one of the major challenges thoracic surgeons may confront from time to time. Fortunately, the vast majority of malignant diseases respond to radiotherapy, chemotherapy, or a combination of the two. Infectious diseases including fungal and tuberculous agents account for the rest of the cases of SVC syndrome, and very few will require surgical decompression.

We have recently used a pulmonary homograft to palliate the symptoms of SVC syndrome in a 72-year-old man with a 2-week history of upper extremity and facial swelling, headaches, and dyspnea. The workup consisted of a computed tomographic scan of the chest, which demonstrated the distended SVC and neck veins but no evidence of intrathoracic malignancy; and a venogram, which revealed a filling defect in the distal SVC. Several attempts at angiographic fine needle aspiration of the mass, suspected to be an endovascular tumor, failed to obtain an adequate tissue sample.

At sternotomy, a constrictive ring in the SVC was found. There were also severe inflammatory reaction and a poorly defined mass in the right hilum. Biopsies of the mass were taken with a Tru-Cut (Allegiance Healthcare, McGaw Park, IL) needle, and a pulmonary homograft (Cryolife, Inc, Kennesaw, GA) was selected to bypass the obstruction. The final histologic examination showed squamous cell carcinoma arising from the lung.

To tailor the distal end of the homograft to the diameter of the innominate vein, we transected the left main pulmonary artery stump with a vascular stapler (Fig 1). The proximal end containing the pulmonic valve apparatus was also excised. Thus, a cylindric conduit 10 cm in length was left to bypass the obstructed SVC. After the thrombus was evacuated with a Fogarty catheter, the graft was anastomosed first to the left innominate vein in an end-to-end fashion and then to the right atrial appendage (Fig 2). The clamps were released, and good filling of the graft was observed. The patency was also confirmed postoperatively by Doppler study of the neck veins.



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  		Fig 1. The homograft’s left main pulmonary artery stump is transected with a vascular stapler, leaving a long, cylindric conduit.

 


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  		Fig 2. Proximal anastomosis between the pulmonary artery homograft root and the left atrial appendage (left lower corner) and distal anastomosis between right pulmonary artery and left innominate vein (right upper corner).

 
We agree with Ohri and associates when they point out that homograft material (either aortic or pulmonary) appears to fulfill the rigorous requirements for an SVC conduit, but, in addition to the lack of proven long-term efficacy, several other factors may limit its use for this purpose. First, homografts are not readily available in the majority of hospitals and they require expensive refrigeration units for their storage. Second, the limited selection of length and diameter favors the spiral vein graft, which can be fashioned to the necessary dimensions. Finally, in an era emphasizing cost containment, the price tag of these conduits of $6,950 in the United States may lessen the enthusiasm of hospital administrators and third-party payers.

References

  1. Ohri S.K., Lawrence D.R., Townsend E.R. Homograft as a conduit for superior vena cava syndrome. Ann Thorac Surg 1997;64:531-533.[Abstract/Free Full Text]
  2. Ross D.N. Evolution of the homograft valve. Ann Thorac Surg 1995;59:565-567.[Free Full Text]
  3. Doty D.B. Bypass of the superior vena cava: six years’ experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease. J Thorac Cardiovasc Surg 1982;83:326-328.[Abstract]



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J. S. Billing, C. D. Sudarshan, P. M. Schofield, F. Murgatroyd, and F. C. Wells
Aortic arch homograft as a bypass conduit for superior vena cava obstruction
Ann. Thorac. Surg., October 1, 2003; 76(4): 1296 - 1297.
[Abstract] [Full Text] [PDF]

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