Ann Thorac Surg 2008;85:2144-2146. doi:10.1016/j.athoracsur.2007.12.027
© 2008 The Society of Thoracic Surgeons
How To Do It
Surgical Management of Tumors Invading the Superior Vena Cava
Alejandro Garcia, MD,
Raja M. Flores, MD*
Division of Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
Accepted for publication December 10, 2007.
* Address correspondence to Dr Flores, Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (Email: floresr{at}mskcc.org).
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Abstract
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Determining the appropriate surgical treatment for anterior mediastinal malignancies, especially those invading the superior vena cava, present a unique problem for thoracic surgeons. Various surgical methods can be applied to resect tumors that have invaded the superior vena cava without the use of cardiopulmonary bypass. The type of procedure used varies according to the size of the tumor and extent of invasion into adjacent structures. This can involve treatment ranging from a simple resection with primary repair to using a vascular shunt and graft interposition. We present a range of methods to approach surgical resection of tumors that have invaded the superior vena cava.
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Introduction
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Historically, mediastinal tumors that had invaded the superior vena cava (SVC) were considered a contraindication to surgical resection. With the advent of prosthetic devices, even the most invasive mediastinal tumors can be resected without the need for cardiopulmonary bypass. We outline different surgical strategies that can be used according to the extent of invasion into the SVC and adjacent structures.
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Technique
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Mediastinal tumors can generally be adequately excised from the SVC by sharp dissection. However, if SVC invasion is suggested or obvious on a preoperative computed tomography scan, then a large-bore access inferior to the heart (ie, femoral vein) should be obtained. If the obstruction has existed for a long time, sufficient collaterals may have developed to allow a clamp and sew technique. When a small section of SVC is invaded by tumor, a partial occlusion clamp may be used for vascular control (Fig 1). Resection of the tumor is performed en bloc with the SVC wall, followed by primary repair. If a large resection of SVC wall is required, patch repair with autologous pericardium may be used to avoid SVC narrowing (Fig 2).
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Fig 1. A partial occlusion clamp is placed over a small tumor invading the superior vena cava (SVC) for vascular control.
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If a large tumor will require a circumferential SVC resection, this may be performed using a vascular shunt and graft interposition with a ringed polytetrafluoroethylene (PTFE) graft or a custom-made bovine pericardial tube (Fig 3). For tumors with extensive SVC and right innominate vein involvement, a graft may first be sewn from the right atrium to the left innominate vein. The tumor resection may then be safely performed en bloc with the SVC and the innominate vein (Figs 4 and 5).
Once the graft is sewn in place, endovascular staplers are useful to transect the proximal and distal SVC. One innominate vein should remain patent at the end of the procedure. Intraoperative management includes intravascular fluid expansion, use of vasoconstrictive agents to keep a high cerebral perfusion pressure, and systemic heparinization.
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Fig 3. Superior vena cava (SVC) resection with graft interposition with a ringed polytetrafluoroethylene graft.
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Fig 4. A graft is sewn from the right atrium to the left innominate vein before tumor resection. (SVC = superior vena cava.)
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Fig 5. A right hemiclamshell thoracotomy is shown. A vascular ringed polytetrafluoroethylene graft is sewn from the right atrium to the left innominate vein before transection. The large black arrow points to left innominate vein. The large white arrow points to the superior vena cava (SVC) completely surrounded by large tumor mass. The small black arrow points to right atrium. The small white arrow points to ascending aorta. A tourniquet is around the right atrium-SVC junction to prevent embolization.
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Comment
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A variety of surgical approaches can be used for resection of mediastinal tumors, depending on their size and extent of invasion [1]. If total SVC clamping is needed during the operation, the SVC should be clamped at the level above the azygos vein to preserve some lateral-branch circulation to minimize brain anoxia. A SVC bypass is generally not necessary if clamping is at this level, but if clamping is below the azygos vein and lasts more than 60 minutes, a SVC bypass should be considered [2]. The preservation of at least one innominate vein to the right heart is necessary; transection of one innominate vein results in temporary unilateral arm swelling that resolves in several weeks.
Complex thoracic resections that require vascular and cardiac resection and reconstruction for curative intent should be offered to patients in whom extrathoracic sites of disease have been excluded. In the case of mediastinal tumors, the need for SVC resection alone should not be considered a contraindication for operation [3]. Whenever the SVC is completely resected, the right phrenic nerve usually requires resection as well; therefore, preoperative pulmonary function testing is essential. Bilateral phrenic nerve invasion is considered an absolute contraindication to surgical intervention. In the appropriate situation, complete surgical resection is feasible given the various surgical techniques described.
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Acknowledgments
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We thank Tony Hokayem for his artwork.
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References
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- Chen K, Xu S, Gu Z, et al. Surgical treatment of complex malignant anterior mediastinal tumors invading the superior vena cava World J Surg 2006;30:162-170.[Medline]
- Spaggiari L, Leo F, Veronesi G, et al. Superior vena cava resection for lung and mediatinal malignancies: a single-center expereince with 70 cases Ann Thorac Surg 2007;83:223-230.[Abstract/Free Full Text]
- Bacha EA, Chapelier AR, Macchiarini P, Fadel E, Dartevelle PG. Surgery for invasive primary mediastinal tumors Ann thorac Surg 1998;66:234-239.[Abstract/Free Full Text]
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Abstract
Introduction
