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Ann Thorac Surg 2003;76:1296-1297
© 2003 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Cambridge, United Kingdom
b Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom
Accepted for publication March 4, 2003.
* Address reprint requests to Dr Billing, Department of Cardiothoracic Surgery, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, United Kingdom
e-mail: stephenbilli{at}hotmail.com
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Abstract |
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Introduction |
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At operation, the vessels were exposed by a median sternotomy and V-shaped neck incision. The SVC was completely occluded at its junction with the innominate vein, which was fibrosed. The right brachiocephalic vein was therefore followed into the neck, identifying patent vein at the confluence of the internal jugular and subclavian veins. The innominate vein was divided and organized thrombus was removed, leaving a patent vessel. An aortic arch homograft (19-mm diameter) was used to reconstruct the venous system, anastomosing the distal end of the graft to the right internal jugular and subclavian junction and the proximal end to the left side of the innominate vein. The left common carotid and left subclavian branches of the homograft were divided at their origin, and the SVC was anastomosed to the neo-orifice thus created. The brachiocephalic arterial stump was closed.
The patient’s symptoms improved dramatically. He made an uneventful recovery and was discharged home on postoperative day 10 on a regimen of formal anticoagulation with warfarin. A subsequent venogram revealed satisfactory drainage into the SVC from both sides, and he remains well.
Case 2
A 43-year-old man presented with increasing chest pain, dyspnea, and bilateral arm swelling. He had a long, complex pacing history, beginning with insertion of a transvenous pacemaker at age 21 for sick sinus syndrome. During the subsequent years he had undergone 9 revisions of his pacing system, because of repeated infections. Most recently a transatrial pacing wire had been implanted through a thoracotomy.
This patient first had superior vena cava obstruction develop in 1992, when a spiral vein graft was performed to bypass the SVC, as reported previously [1]. A second bypass procedure using a prosthetic graft was performed in 1999. On this occasion, symptoms of SVC obstruction had been present for 1 month, with the patient reporting increasingly severe headaches that were only partially relieved by sitting upright. Consequently the patient was unable to sleep, and he could not move his head quickly in either direction without severely exacerbating the pain. He also became progressively more breathless. On examination he was dyspneic, with engorged neck veins and bilateral arm edema. Venography confirmed the presence of occlusion of his arm veins to below the level of the shoulder bilaterally. Percutaneous approaches for stenting of the SVC were not possible.
At operation, the right internal jugular vein was identified, but this was empty and fibrosed up to the level of the base of skull. The left neck was explored, revealing a large, patent left internal jugular vein with palpably high pressure. At median sternotomy a synthetic graft was identified running from the right anterior jugular vein to the right atrium, but this was completely thrombosed and was excised. The spiral vein graft was dissected out, running from the innominate vein to the right atrium, and this graft was patent. The innominate vein was thrombosed centrally.
Two aortic arch homografts were used to reconstruct the venous drainage of the head and neck. The proximal end of the first homograft was anastomosed end-to-side to the left internal jugular vein and the distal end was then anastomosed to the superior end of the previous spiral vein graft. Once clamps were removed, the pressure in the jugular vein was still very high, indicating incomplete relief of the venous obstruction. Therefore a second aortic arch homograft was used as a further bypass conduit. This was anastomosed end-to-side to the first homograft and distally, again inverted, to the right atrium (Fig 1). The distal anastomosis was performed on cardiopulmonary bypass after cannulation of the aorta, inferior vena cava, and the second homograft through the carotid artery branch. Great vessel branches arising from the aortic arch homografts were oversewn. The atrial anastomosis of the spiral vein graft was found to be severely narrowed.
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Comment
Superior vena cava obstruction is becoming well recognized as a complication of long-term transvenous devices, including pacemakers [2, 3], defibrillator leads, and implantable venous access systems. The incidence of superior vena cava obstruction among pacemaker patients is low, certainly less than 1 in 1,000 [2, 3], but increasing use of pacemakers and implantable cardioverter-defibrillators may lead to a significant number of patients with symptomatic and life-threatening superior vena cava obstruction.
The cause of transvenous device-related SVC obstruction appears to be a combination of thrombosis and fibrosis. Fibrin deposition along pacemaker electrodes has been found at autopsy, with fibrotic attachments to the SVC wall and endocardium. Excessive fibrin deposition, such as in the presence of severed leads, multiple leads, or infection [2] would cause venous fibrosis, as found in 24% of patients with superior vena cava obstruction [3].
Some success has been achieved treating pacemaker-induced venous thrombosis by anticoagulation, thrombolysis [3], and percutaneous angioplasty [2, 3]. Nonetheless, there remain some patients with life-threatening SVC obstruction who require surgical intervention. One surgical approach is to perform thrombectomy and patch repair of the SVC [2]. Alternatively, the obstructed SVC can be bypassed, using a spiral vein graft [1, 4], autologous femoral vein, or a homograft as a conduit. There have been two previous case reports of homograft use in SVC syndrome; one case after resection of the native SVC [5] and the other for SVC obstruction caused by malignant infiltration [6].
Patch repair of the SVC [2] and spiral vein graft bypass [4] have both proved susceptible to restenosis, as in case 2. The aortic arch homograft bypass technique reported in this article provides a large caliber conduit, less thrombogenic than a synthetic graft, and the large anastomoses are less prone to restenosis. In addition, the great vessels branching from the aortic arch homograft offer considerable flexibility, such as the possibility of reconstructing the venous drainage from both sides of the head and neck, as in case 1. Homograft bypass would be suitable for patients with symptomatic SVC obstruction in whom nonsurgical approaches are unsuccessful or impossible.
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  R. K. Praseedom, P. Dhar, N. V. Jamieson, J. Wallwork, I. Bergman, and D. J. Lomas Leiomyosarcoma of the Retrohepatic Vena Cava Treated by Excision and Reconstruction With an Aortic Homograft: A Case Report and Review of Literature Surgical Innovation, December 1, 2007; 14(4): 287 - 291. [Abstract] [PDF]
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