Ann Thorac Surg 2010;89:631-633. doi:10.1016/j.athoracsur.2009.04.146
© 2010 The Society of Thoracic Surgeons
Case Reports
Radical Resection of the Superior Vena Cava Using the Contegra Bovine Jugular Vein Conduit
Elizabeth Belcher, FRCS, PhDa,
Michael Dusmet, MDa,
Mario Petrou, FRCS, PhDb,*
a Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom
b Department of Adult Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom
Accepted for publication April 6, 2009.
* Address correspondence to Dr Petrou, Department of Adult Cardiac Surgery, Royal Brompton Hospital, Sydney St, London, SW3 6NP, United Kingdom (Email: m.petrou{at}rhht.nhs.uk).
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Abstract
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Radical resection of the superior vena cava poses a challenge for the cardiothoracic surgeon. The Contegra graft (Medtronic Inc, Minneapolis, MN), a biologic conduit comprising the valved segment of the bovine jugular vein, is established as a right ventricular to pulmonary artery conduit for right ventricular outflow tract repair in the pediatric population. We describe the use of the Contegra graft to facilitate radical resection and reconstruction of the superior vena cava in 2 patients, with demonstrable patency of grafts at 12 months and 7 months postoperatively.
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Introduction
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Resection of anterior mediastinal masses involving the superior vena cava (SVC) poses a challenge for the cardiothoracic surgeon. Often, these tumors are regarded as irresectable; however, potentially curative radical resection with SVC replacement is possible in selected patients. The choice of conduit for total SVC replacement is limited, and we describe the use of the Contegra graft (Medtronic Inc, Minneapolis, MN) in this setting.
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Case Reports
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Patient 1
A 48-year-old woman with severe scleroderma and a progressively enlarging anterior mediastinal mass, presumed to be thymoma, was referred for surgical intervention. Infiltration of the mass into the SVC necessitated radical resection, and extended thymectomy was undertaken. Full right atrial to aortic cardiopulmonary bypass was instituted. The left and right brachiocephalic veins and the right atrium proximal to the cavoatrial junction were clamped and the anterior mediastinal mass and SVC excised en bloc. An 18-mm Contegra graft bovine jugular conduit was used for the reconstruction. The patient remains well, with a patent conduit demonstrable on computed tomography (CT) at 12 months.
Patient 2
A 73-year-old woman presented with superior vena caval obstruction (SVCO) secondary to malignant thymoma. After induction chemoradiation, CT (Fig 1) and magnetic resonance imaging showed a residual 7-cm anterior mediastinal mass filling the entire SVC from the confluence of the left and right brachiocephalic veins to the superior aspect of the right atrium 1.5 cm distal to cavoatrial junction. Radical thymectomy was undertaken. Full cardiopulmonary bypass was used with a single venous cannula and inferior vena caval snare with upper body cardiotomy suction bypass. The left brachiocephalic vein was occluded and therefore sacrificed. Reconstruction with an 18-mm Contegra graft was performed (Fig 2). The patient remains well, with a patent conduit demonstrable on CT at 7 months (Fig 3).
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Fig 1. Contrast computed tomography scan of the chest shows an anterior mediastinal mass in continuity with the superior vena cava, which has a filling defect (arrow) suggestive of direct tumor invasion or intraluminal thrombus.
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Fig 3. Contrast computed tomography scan of the chest shows a patent Contegra graft (arrow) in the superior vena cava position 7 months postoperatively.
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Both patients were commenced on warfarin postoperatively to maintain an international normalized ratio of between 2 and 3 for 3 months. Both remain well, with patent grafts on contrast CT at 12 and 7 months postoperatively, respectively.
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Comment
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Resection of the anterior mediastinal mass involving the SVC poses a challenge for the cardiothoracic surgeon in patients both with and without SVCO. The use of polytetrafluoroethylene (PTFE), pericardial tube, and spiral vein grafts has been reported for SVC reconstruction. The long-term results reflect the primary diagnosis and stage; therefore, freedom from recurrent SVCO is an important end point. PTFE and pericardial tube grafts have a significance incidence of thrombosis and SVCO. Although spiral vein grafts are probably associated with the best long-term patency rates, there is an incidence of graft occlusion and recurrent SVCO requiring multiple revisions [1].
The Contegra graft consists of bovine jugular vein with a trileaflet valve and is indicated for the reconstruction of the right ventricular outflow tract in the pediatric population, with good long-term freedom from graft dysfunction and reoperation [2]. We used the Contegra graft for SVC reconstruction in 2 patients who required extended resection of anterior mediastinal masses.
Inferior vena cava snare with upper-body cardiotomy suction was used in the patient with SVCO. Avoidance of upper-body venous clamping during cardiopulmonary bypass in patients with SVCO may prevent the decrease in cerebral perfusion pressure that will occur as a result of impedance to SVC flow due to clamping and the reduction in mean arterial pressure associated with cardiopulmonary bypass.
The use of a double Contegra graft to reestablish venous drainage after inadvertent injury during an elective cardiac procedure was recently reported. An acute SVCO developed on cessation of warfarin therapy at 1 month postoperatively, with narrowing of the right-sided conduit and complete obstruction of the left conduit, necessitating percutaneous angioplasty and stenting [3]. Lu and colleagues [4] removed the valve before implantation and ligated the azygous vein in an attempt to reduce the possibility of thrombus formation in a patient with SVCO undergoing radical thymectomy. Their patient received warfarin anticoagulation for 6 months and was free from SVCO at 42 months postoperatively. Warfarin therapy should probably be continued for 3 to 6 months after SVC reconstruction with the Contegra graft.
Sacrifice of the left innominate vein in this patient was performed without consequence. Although occluded in our patient, sacrifice of a patent left innominate vein has been shown to be without long-term sequelae in the setting of aortic operations [5].
We describe 2 patients with SVC reconstruction with Contegra grafts, with clinical and radiologic freedom from SVCO at 12 and 7 months postoperatively. We recommend the use of the Contegra graft when radical replacement of the SVC is indicated.
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References
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- Doty JR, Flores JH, Doty DB. Superior vena cava obstruction: bypass using spiral vein graft Ann Thorac Surg 1999;67:1111-1116.[Abstract/Free Full Text]
- Breymann T, Boethig D, Goerg R, Thies WR. The Contegra bovine valved jugular vein conduit for pediatric RVOT reconstruction: 4 years experience with 108 patients J Card Surg 2004;19:426-431.[Medline]
- Xu G, Alexiou C, Tofeig M, Spyt TJ. Management of superior vena cava obstruction syndrome due to thrombus of the Contegra conduit used to re-establish vein-to right atrium continuity Interact Cardiovasc Thorac Surg 2007;6:517-518.[Abstract/Free Full Text]
- Lu WD, Yu FL, Wu ZS. Superior vena cava reconstruction using bovine jugular vein conduit Eur J Cardiothoracic Surg 2007;32:816-817.[Abstract/Free Full Text]
- Sai Sudhakar CB, Elefteriades JA. Safety of left innominate vein division during aortic arch surgery Ann Thorac Surg 2000;70:856-858.[Abstract/Free Full Text]
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Abstract
Introduction
