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Ann Thorac Surg 1998;66:291-292
© 1998 The Society of Thoracic Surgeons

Updates

Superior Vena Caval Reconstruction Using Autologous Pericardium

William H. Warren, MDa, William J. Piccione, Jr, MDa, L. Penfield Faber, MDa

a Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois, USA

Address reprint requests to Dr Warren, Rush-Presbyterian-St. Luke’s Medical Center, 1725 W Harrison St, Suite 218, Chicago, IL 60612

Partial or complete occlusion of the superior vena cava (SVC) by malignant tumor is frequently considered by many clinicians to be an indisputable sign of unresectability. Neoadjuvant therapy for locally advanced non–small cell lung carcinoma and malignant mediastinal tumors has enhanced the ability of the thoracic surgeon to accomplish a complete resection, including a portion or all of the SVC. If collateral circulation has not developed in the face of obstruction of the SVC, prolonged cross-clamping of the venous drainage to the upper third of the patient’s body can result in acute cerebral edema. Dartevelle and associates [1, 2] have described a technique for cross-clamping and replacement of the SVC with minimal complications. However, we have been reluctant to resect the SVC with this technique, preferring instead to fashion a shunt maintaining upper venous drainage and avoiding this possibly fatal neurologic complication.

The technique described in our original article [3] uses an intraluminal shunt to permit continuous venous flow into the right atrium during resection and reconstruction of the superior vena cava under very controlled conditions. Rather than performing an en-bloc resection of the lung, nodes, and SVC as advocated by others [4], we chose to complete the pulmonary resection first, optimizing the exposure for the SVC resection and reconstruction. In most cases, the defect can be closed with either a patch or direct suture repair. If complete resection and tube graft replacement of the vena cava is required, the shunt can be repositioned through the graft during a very short period of cross-clamping.

Our updated experience with this technique is presented in Table 1. Follow-up of our initial 6 patients is provided, together with our experience with an additional 5 patients. We continue to favor the use of pericardium as our material of choice to patch the SVC defect, although others have successfully used a thin polytetrafluoroethylene cardiovascular patch. In 2 patients, the entire circumference of the SVC was resected, necessitating an interposition graft of externally supported 13-mm polytetrafluoroethylene as described by others [5–7].


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  		Table 1. Patient Data

 
In patient 9, the presence of a central venous access catheter precluded complete control using the shunt technique. The resulting defect in the SVC was patched while the SVC was cross-clamped for 9 minutes. During the cross-clamp time, the blood pressure was maintained at 80/50 mm Hg. The face was markedly congested for the period of clamping, but these findings quickly resolved as soon as the clamps were released. Postoperatively, this patient remained unresponsive and ventilator dependent for 4 days. During this time, pupils responded sluggishly to light and an electroencephalogram showed diffusely slowed low-voltage brain wave activity. Over the course of the next 2 weeks, the patient made a complete recovery and is alive without evidence of recurrence 6 years after a resection. This experience, and the absence of any neurologic problems in shunted patients, have encouraged us to shunt rather than cross-clamp the SVC. The long-term patency of the SVC and the absence of thrombus or pulmonary emboli even without anticoagulation have been gratifying.

The 5-year survival in 4 of 11 patients indicates that an aggressive approach to these locally advanced malignancies is justified.

Footnotes

As originally published in 1990: superior vena caval reconstruction using autologous pericardium
Updated in 1998

References

  1. Dartevelle P.G., Chapelier A.R., Pastorino U., et al. Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259-265.[Abstract]
  2. Dartevelle P., Macchiarini P., Chapelier A. Technique of superior vena cava resection and reconstruction. Chest Surg Clin North Am 1995;5:345-358.[Medline]
  3. Piccione W., Jr, Faber L.P., Warren W.H. Superior vena caval reconstruction using autologous pericardium. Ann Thorac Surg 1990;50:417-419.[Abstract]
  4. Yoshimura H., Kazama S., Asari H., et al. Lung cancer involving the superior vena cava: pneumonectomy with concomitant partial resection of superior vena cava. J Thorac Cardiovasc Surg 1979;77:84-86.
  5. Masuda H., Ogata T., Kikuchi K., et al. Longevity of expanded polytetrafluoroethylene grafts for superior vena cava. Ann Thorac Surg 1989;48:376-380.[Abstract]
  6. Nakahara K., Ohno K., Mastumura A., et al. Extended operation for lung cancer invading the aortic arch and superior vena cava. J Thorac Cardiovasc Surg 1989;97:428-433.[Abstract]
  7. Mori Y., Hadama T., Takasaki K., et al. Reconstruction of the superior vena cava with externally stented Gore-Tex graft for malignant diseases. Thai J Surg 1987;8:53-56.



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