Ann Thorac Surg 2006;82:310-312
© 2006 The Society of Thoracic Surgeons
Case report
Management of Superior Vena Cava Syndrome by Internal Jugular to Femoral Vein Bypass
Rajinder Singh Dhaliwal, MS, MCh,
Debasis Das, MS, MCh
*
,
Suvitesh Luthra, MS, MCh,
Jaswinder Singh, MS,
Sudhir Mehta, MS,
Harkant Singh, MS
Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Accepted for publication August 29, 2005.
* Address correspondence to Dr Das, Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, PIN, 160012 India (Email: dasdeba{at}yahoo.com).
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Abstract
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We report a 30-year-old man with superior vena cava syndrome due to fibrosis from a previously irradiated malignant thymoma. The patient presented 4 years after the initial treatment, after having been lost to follow-up. Investigations revealed total obstruction of the superior vena cava, and right subclavian and right internal jugular vein. The patient underwent an extra-anatomic bypass (ringed polytetrafluoroethylene graft 10-mm diameter) between the left internal jugular vein and the left femoral vein brought in a subcutaneous tunnel over the anterior chest and abdominal wall. Entry to the thoracic cavity was avoided due to extensive fibrotic changes visualized in the computed tomographic chest scan. Follow-up Doppler at 2 months, 6 months, 1 year, and 3 years showed a patent graft. An internal jugular vein to the femoral vein bypass is a simple method for palliation of superior vena cava syndrome.
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Introduction
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Superior vena cava (SVC) syndrome is a disabling and potentially life-threatening condition resulting from a complication of neoplastic or inflammatory disease of the mediastinum. Bronchogenic carcinoma, metastatic pulmonary, or mediastinal malignancy is the most frequent cause of SVC syndrome. Several techniques for bypass of the SVC to relieve severe symptoms have been described; these techniques have used spiraled saphenous vein grafts [1, 2], femoral vein grafts [3], and polytetrafluoroethylene grafts [4] as conduits. The most common bypass done is made between the internal jugular vein and the right atrium. Endovascular treatment has emerged as a newer modality for treatment of SVC syndrome [5]. There are few reports of extra-anatomic subcutaneous bypass between the jugular vein and the femoral vein [6, 7].
A 30-year-old man presented with facial swelling, engorged neck veins, and dizziness for the prior 3 months. The patient had presented 4 years before with similar complaints and was diagnosed to have malignant thymoma that was unresectable. The patient received two cycles of radiotherapy and was lost to follow-up. Presently the patient had facial puffiness with engorged veins of the face, neck, and anterior chest wall. His remaining general physical and systemic examination was normal. A chest roentgenogram showed homogenous opacity in the right paratracheal and right hilar region. Computed tomographic scan showed fibrotic changes in the superior mediastinum with an ill-defined mass infiltrating into the SVC. A venogram of the SVC showed total obstruction of the SVC with right subclavian vein obstruction. A Doppler of the neck veins showed the right internal jugular vein to be thrombosed. Written informed consent was taken from the patient before the procedure. The patient was successfully palliated of his symptoms by an extra-anatomic bypass (ringed polytetrafluoroethylene graft 10-mm diameter) between the left internal jugular vein and the left femoral vein brought in a subcutaneous tunnel over the anterior chest and abdominal wall. The patient was anticoagulated with warfarin for 2 months, and then he was prescribed low-dose aspirin therapy. A follow-up Doppler (Fig 1) was performed at 2 months, 6 months, 1 year, and 3 years, which showed a patent graft. Computed tomography angiogram (Figs 2 and 3)
confirmed the same findings at 3 years follow-up.
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Fig 2. Computed tomographic angiogram (coronal reconstruction) showing patent graft at 3 years follow-up.
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Comment
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Surgical or endovascular treatment should be considered in patients with SVC syndrome with severe symptoms [8]. Studies of endovascular treatment of nonmalignant SVC syndrome are limited to case reports and small series with short follow-ups [5].
Superior vena cava syndrome has been treated surgically by an internal jugular to the right atrium bypass. Spiral saphenous vein graft, an autologous tissue with low thrombogenicity was first used by Doty and colleagues [1, 2] to bypass the SVC. An expanded polytetrafluoroethylene graft has also been used to bypass the SVC. Recurrent SVC syndrome has been successfully managed with an externally supported femoral vein bypass graft [3].
Saphenojugular bypass as palliative therapy of SVC syndrome caused by bronchial carcinoma was described in 7 patients by Vineze and colleagues [6]. The authors showed that the procedure was just as satisfactory as the results of other operations described for treatment of SVC syndrome. Relief of SVC syndrome by a modified saphenojugular bypass graft has also been described in which a bypass from the right internal jugular to the femoral vein was performed with spliced bilateral greater saphenous veins tunneled inside an externally supported expanded polytetrafluoroethylene graft [7].
Our patient received a ringed polytetrafluoroethylene 10-mm diameter bypass graft from the left internal jugular vein to the left femoral vein brought in a subcutaneous tunnel over the anterior chest and anterior wall. The advantage of this approach is that it avoids entry into the chest, especially useful in situations with extensive mediastinal fibrosis. The graft has remained patent until 3 years of follow-up, and the patient has been relieved of his symptoms. Thus an internal jugular vein to femoral bypass is a unique, simple method for palliation of SVC syndrome.
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References
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- Doty DB, Baker WH. Bypass of superior vena cava with spiral vein graft Ann Thorac Surg 1976;22:490-493.[Abstract]
- Doty DB. Bypass of superior vena cavasix years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease. J Thorac Cardiovasc Surg 1982;83:326-338.[Abstract]
- Marshall Jr WG, Kouchoukos NT. Management of recurrent superior vena caval syndrome with an externally supported femoral vein bypass graft Ann Thorac Surg 1988;46:239-241.[Abstract]
- Avasthi RB, Moghissi K. Malignant obstruction of the superior vena cava and its palliation report of four cases J Thorac Cardiovasc Surg 1977;74:244-248.[Abstract]
- Kalra M, Gloviczki P, Andrews JC, et al. Open surgical and endovascular treatment of superior vena cava syndrome caused by non-malignant disease J Vasc Surg 2003;38(2):215-223.[Medline]
- Vineze K, Kulka F, Csorba L. Sapheno-jugular bypass as palliative therapy of superior vena cava syndrome caused by bronchial carcinoma J Thorac Cardiovasc Surg 1982;83:272-277.[Abstract]
- Panneton JM, Andrews JC, Hoter JM. Superior vena cava syndromerelief with a modified sapheno-jugular bypass graft. J Vasc Surg 2001;34(2):360-363.[Medline]
- Gloviczki P, Vrtiska TJ. Surgical treatment of superior vena cava syndromeIn: Rutherford RB, editor. Vascular surgery. 5th ed. Philadelphia, PA: WB Saunders; 2000. pp. 2093-2104.
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L. D. Wilson, F. C. Detterbeck, and J. Yahalom
Superior Vena Cava Syndrome with Malignant Causes
N. Engl. J. Med.,
May 3, 2007;
356(18):
1862 - 1869.
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Abstract
Introduction
