Adult Chest Surgery

Chapter 140. Resection for Superior Vena Cava Syndrome 

The superior vena cava (SVC) syndrome is a clinical disorder caused by compression or obstruction of the SVC. The signs and symptoms associated with this syndrome are swelling of the face, neck, and arms; cough; nasal congestion; visual disturbance; dyspnea; orthopnea; headaches; dizziness; and syncope. Serious symptoms secondary to severe laryngeal and cerebral venous congestion often require urgent intervention. The severity of the symptoms depends on the extent of obstruction and degree of collateral circulation. Generally speaking, a slowly progressive process has a well-developed collateral circulation, and the symptoms tend to be less severe.

SVC obstruction may be caused by malignant or benign disease, or it may have an iatrogenic etiology. Malignancy is the most common cause of the SVC syndrome.1–4 Benign processes include histoplasmosis, fibrosing mediastinitis, thrombosis, infection, aneurysm, benign tumors, and idiopathic etiologies.3–5 The iatrogenic causes include radiation therapy, IV catheters, and transvenous pacemaker leads. IV devices have been reported to be the leading cause of benign SVC syndrome.4

Most cases of SVC obstruction encountered by the thoracic surgeon are caused by malignant or benign mediastinal tumors. Mediastinal masses obstruct the SVC through extrinsic compression, intravascular invasion, or secondary thrombosis as a result of flow turbulence or the patient's hypercoagulatory status. Inciting malignancies include bronchogenic carcinoma, lymphoma, metastatic cancer, malignant germ cell tumor, and malignant thymic tumor, among others.1–4 Bronchogenic carcinoma is the most common cause of adult malignant SVC syndrome. Nieto and Doty reported that bronchogenic cancer accounts for 67–82% of all cases of SVC syndrome and lymphomas for 5–15%.In a more recent review, Rice and colleagues reported that bronchogenic carcinoma accounts for 46–78% of cases of SVC syndrome and lymphomas for 8%.Among bronchogenic carcinomas, squamous cell and small cell carcinomas are common.1,3 In children, lymphoma is the most common cause of SVC syndrome.Benign tumors that cause SVC obstruction include thymoma, teratoma, substernal thyroid goiter, cystic hygroma, and dermoid cyst, among others.5

The two circumstances in which surgical treatment of the SVC syndrome is considered include resection of an obstructing tumor and severe refractory syndrome. We describe the surgical management of SVC syndrome secondary to obstruction by malignant and benign mediastinal tumors, with particular focus on resection and reconstruction of the SVC with cardiopulmonary bypass (CPB).

SURGICAL PRINCIPLES AND PATIENT SELECTION

The goal of surgical management of SVC obstruction is relief of the SVC syndrome, complete resection of the tumor, or both. Clarifying the goal is essential to affecting a reasonable surgical plan. The surgical indications for SVC obstruction of benign etiology are (1) severe SVC syndrome that cannot be alleviated by conservative therapy, (2) a tumor that is causing serious obstruction or compression of other organs such as a lung, trachea, heart, or aorta, and (3) a functional hormone-excreting tumor that is causing adverse symptoms that cannot be alleviated by conservative therapy.

Benign tumors tend to grow slowly, and the SVC compression progresses gradually. Thus the collateral circulation develops well, and the patient is often able to tolerate the obstruction. However, some patients suffer from persistent symptoms that may need to be managed surgically. Tumors that cause tracheal compression or tumors that excrete hormones resulting in hormone-related symptoms that are refractory to conservative treatment must be resected. Such tumors are often found adherent to the SVC and can be managed by CPB if simple clamping and shunt prove to be too cumbersome. If symptom relief is the only goal of surgery, less invasive procedures, such as anatomic or extraanatomic bypass and endovascular stenting, should be considered.

The surgical indications for SVC obstruction of malignant etiology are (1) severe SVC syndrome that cannot be alleviated by conservative therapy, (2) acute SVC obstruction with signs of laryngeal or cerebral edema, and (3) a resectable process that invades the SVC regardless of symptoms.

Complete resection of the tumor, including the SVC, should be considered only when the disease is potentially curable. Otherwise, symptom relief is the primary goal of surgery, and less invasive palliative procedures, such as extraanatomic bypass and endovascular stenting, should be considered. Acute SVC obstruction accompanied by hemodynamic instability also warrants palliative treatment because these patients generally cannot tolerate a radical procedure.

Combined resection and reconstruction of the SVC is an invasive and technically demanding procedure. It should be performed by an experienced surgeon and then only when the expected surgical benefit outweighs the potential surgical risk. The resectability and prognosis of the tumor and the patient's surgical risks need to be assessed carefully in the decision-making process.

Extraanatomic bypass is used as a palliative treatment for high-risk patients or patients with incurable malignant SVC syndrome. A graft is placed subcutaneously between the axillary or jugular vein and the femoral or saphenous vein.10 The endovascular procedure is an effective option for treating both benign and malignant disease when symptom relief is the only goal of surgery.7,8 However, a previous study has shown that the rate of symptom relief at 1 year in the endovascular procedure group was significantly lower than that of the surgical group and that repeated endovascular procedures were required to obtain similar symptom relief.Endovascular angioplasty and stenting of the SVC always should be performed in a hospital setting with surgeons on standby for unexpected events such as rupture of the SVC.

PREOPERATIVE ASSESSMENT

The preoperative assessment includes a thorough analysis of patient risk and accurate diagnosis of the primary disease. A number of diagnostic procedures are available to determine the location and degree of the SVC obstruction, involvement of cardiac component and other great vessels, and degree of collateral circulation. Assessment of the collateral circulation is critical for reconstruction of the SVC and its tributaries. This chapter focuses on the anatomic relationship of the great vessels, collateral circulation, and cardiac component of the preoperative assessment. Specific features of mediastinal tumor pathology are discussed in Chapters 137 and 139.

Computed Tomography

A chest CT scan is the most informative diagnostic procedure for detecting the size and location of the tumor, evidence of direct invasion of other organs, and the presence of metastatic disease. This information is essential to evaluating tumor resectability in patients with SVC obstruction. The anatomy of the SVC, heart, and other great vessels in relation to the tumor can be clearly visualized on multiplanar and three-dimensional images. Additionally, three-dimensional volume-rendering technique can provide accurate information about the collateral circulation.10

Echocardiography

Echocardiography can be used to assess the relationship between the tumor and the cardiac apparatus (e.g., cavoatrial junction, valves, and coronary arteries). Transesophageal echocardiography generally provides more information than transthoracic echocardiography. Geibel and colleagues reported that transesophageal echocardiography was superior for diagnosing myocardial infiltration.11 Transesophageal echocardiography can visualize the SVC, particularly the central portion near the atrium, and is a dynamic procedure that permits assessment of the mobility of the tumor and obstruction.12

Venography

Venography is used to assess the location and degree of SVC obstruction and collateral venous circulation. Based on venographic findings, SVC obstructions are categorized as four types13 (Table 140-1).

Table 140-1. Venographic Classification of SVC Obstruction

·   Type I: Moderate obstruction (up to 90%) of the SVC with patent antegrade flow of the azygos vein

·   Type II: Severe obstruction (90–100%) of the SVC with patent antegrade flow of the azygos vein

·   Type III: Severe obstruction of the SVC with reversal flow of the azygos vein

·   Type IV: Complete obstruction of the SVC and azygos vein

 

 

Magnetic Resonance Imaging

MRI is an alternative procedure for evaluating the primary tumor. Contrast-enhanced MR venography is also useful for evaluating the SVC and its tributaries. It is less invasive than classic venography but more costly.

SURGICAL MANAGEMENT

Approach

Median sternotomy is the preferred approach because it provides easy access to the SVC, both brachiocephalic veins, the aorta, and both atria. Right thoracotomy may be an option if the primary tumor is located in the right chest and involvement of the SVC and heart is limited. The aorta and both venae cavae can be reached through the fourth or fifth intercostal spaces by right thoracotomy. A hemiclamshell approach is another good alternative, and an upper hemisternotomy may be an option.

An upper hemisternotomy incision is made (Fig. 140-1). The sternum is divided from the sternal notch down to the fourth intercostal space using a regular sternal saw and then divided transversely to the right fourth intercostal space using an oscillating saw. This approach provides easy access to the SVC, left brachiocephalic vein, right atrial appendage, and aorta. When CPB is required, the ascending aorta is cannulated directly through the incision, and the right atrium is cannulated directly through the incision or percutaneously through the femoral vein. Because access to the free right atrial wall and right pleural space is limited, this approach is suitable only for small benign tumors or palliative bypass procedures.

Figure 140-1.

 

Upper hemisternotomy.

Management of the Venous Circulation

If the collateral circulation is well developed, resection and reconstruction of the SVC can be performed with simple clamping after heparin administration. If the collateral circulation is poorly developed, simple clamping should be avoided because the cardiac output will be reduced secondary to the reduced venous return. It may be possible to manage the patient's hemodynamic status with fluid and vasoactive agents. However, if fluids and medication are ineffective, the venous circulation returning to the heart must be maintained by using an intraluminal shunt, other venous bypass, or CPB.

The left brachiocephalic vein to right atrial appendage is a common bypass technique used in this setting. A large vascular clamp is placed on the right appendage, which is opened. After excising some trabecular muscle, a graft is anastomosed to the appendage by using continuous 4-0 polypropylene sutures. Removing a portion of the trabecular muscle prevents obstructed flow gradient. The left brachiocephalic vein is clamped proximally and distally and divided. The graft is anastomosed in end-to-end fashion using continuous 5-0 or 6-0 polypropylene sutures. After replacing the venous return from the left brachiocephalic vein, the SVC or right brachiocephalic vein can be clamped for resection and reconstruction.

CPB is used when there is involvement of the heart or aorta necessitating resection. Although CPB increases the invasiveness of the surgery and can cause adverse effects on various organs, it provides safe hemodynamic control in an environment that is conducive to complete resection. The availability of CPB also provides a safety net in the event of injury to cardiovascular structures during tumor resection.14

Strategy for Cardiopulmonary Bypass

Portions of the tumor that can be resected safely without CPB should be removed before bypass is instituted to minimize blood loss and overall duration of CPB. If the situation warrants, however, CPB may be established before dissection of the tumor to ensure safe manipulation. After adequate heparinization, the ascending aorta is cannulated in standard fashion. When the aorta is invaded by the tumor, the cannula is placed distally to create a sufficient margin between the aortic cross-clamp and the tumor. The SVC and inferior vena cava are cannulated. If the cannula does not fit in the SVC, the left brachiocephalic vein is cannulated instead. We use a 24F single-stage flexible cannula for the SVC, inferior vena cava, and left brachiocephalic vein. When the left and right brachiocephalic veins are separately reconstructed, the cannula in the left brachiocephalic vein is snared with a tourniquet, and the right brachiocephalic vein is clamped. Unilateral clamping is usually tolerated well in patients with chronic obstruction. If the right brachiocephalic vein is prominently distended or CPB flow significantly decreases, placing a small cardiotomy suction tube (12–16F) in the right brachiocephalic vein is a useful technique to establish the venous return. When the ascending aorta is resected, the aortic cross-clamp is applied, and the antegrade cardioplegia is administered to obtain diastolic arrest of the heart. When the distal ascending aorta or aortic arch is resected, deep hypothermic circulatory arrest may be required. The patient is weaned from CPB in standard fashion after the resection and reconstruction is complete. Protamine is administered to reverse heparin after the patient has been weaned.

Reconstruction

For limited reconstructions, the SVC can be sutured directly or a pericardial patch angioplasty can be performed. Otherwise, the SVC is reconstructed using one of a variety of vascular grafts and one of several methods. The method used for reconstruction is based on the location of venous involvement, collateral circulation, and intraoperative circulation management. In principle, the grafts should be short and straight to avoid kinking and thrombosis, and an end-to-end anastomosis generally is preferred over an end-to-side anastomosis. When only the SVC is reconstructed, a graft is anastomosed to the distal end of the remaining SVC and superior cavoatrial junction or right atrial appendage. When the right and left brachiocephalic veins are reconstructed separately, several reconstruction patterns are possible: a single right brachiocephalic graft, a single left brachiocephalic graft, two separate grafts to the right atrium, or a Y-graft (Fig. 140-2). It is usually unnecessary to reconstruct the azygos vein, but when this is necessary, it is anastomosed to the SVC graft in an end-to-side fashion with or without interposition of a short 6- or 8-mm ringed expanded polytetrafluoroethylene (ePTFE) graft.

Figure 140-2.

 

A. Right brachiocephalic vein graft. B. Left brachiocephalic vein graft. C. Two separate grafts to the right atrium. D. Y-graft.

Graft Selection

Several types of grafts are available for SVC reconstruction. Each graft has specific advantages and disadvantages. Grafts should be chosen based on multiple factors, including anatomy, primary disease characteristics, prognosis, and graft availability. Careful selection of appropriate diameter and length is critical. Diameter mismatch can cause residual obstructive flow and symptoms and, secondarily, graft thrombosis. Length mismatch can cause excessive tension or kinking.

RINGED EXPANDED POLYTETRAFLUOROETHYLENE GRAFT

The ringed ePTFE graft is the most common prosthetic material used for reconstruction of large veins. The advantages are availability, ease of use, and wide range of sizes. Using a prosthetic graft also saves time because there is no need for advance preparation. Furthermore, this ring-supported material is less likely to kink or succumb to extrinsic compression than other biologic materials. Generally, prosthetic grafts have inferior patency to biologic grafts for veins. However, long-term patency has been shown to be favorable when it is used for SVC reconstruction.15,16 This graft is not as well suited for reconstruction of small peripheral veins because of the high incidence of thrombosis. The ePTFE graft is used most commonly for malignant SVC obstruction. A graft diameter of 12-14 mm is used for the SVC, and 8- to 12-mm grafts are used for its tributaries in most cases. Anticoagulation is required to prevent graft thrombosis.

PERICARDIAL GRAFT

Autologous and bovine pericardium is often used for patch angioplasty,31 but a pericardial tube graft is also used for reconstructing the SVC in benign and malignant disease.17,18 Long-term patency in a human study has not been systematically reported. Anticoagulation is not required, but temporary use may be helpful to reduce the risk of thrombosis. The disadvantage of using autologous pericardial graft is its limited availability. Bovine pericardium, on the other hand, is widely available in a range of sizes. The pericardial tube is constructed by wrapping the pericardial graft around a chest tube or plastic syringe of appropriate diameter and approximating the edges with continuous 4-0 or 5-0 polypropylene sutures. Using metal staples instead of sutures is a helpful time-saving technique.18

SPIRAL SAPHENOUS VENOUS GRAFT

Spiral saphenous vein graft has been reported to have an excellent long-term patency rate that is superior to that of other graft materials.19,20 This may be the best option in terms of its tissue compatibility, low thrombogenicity, and long-term patency. However, it requires additional operative time and incisions to harvest the graft. The length of graft is limited by the available segment of the saphenous vein. Varicose vein is not a favorable material. The required length of saphenous vein is determined by the desired graft diameter and length and the average diameter of the saphenous vein.20 To make a 10-cm spiral vein graft, the saphenous vein needs to be harvested roughly from the groin to the knee. The saphenous vein is harvested with classic open technique or endoscopic technique. Endoscopic vein harvest provides smaller incisions and less frequent incidence of wound infection.18 After harvesting the required length of saphenous vein, the vein is opened longitudinally, and the valves are excised. The opened vein is wrapped around a chest tube of appropriate size (usually 28–36F), and the edges of the saphenous vein are sutured with running 6-0 or 7-0 polypropylene sutures.

OTHER GRAFTS

Use of the superficial femoral vein for the SVC reconstruction has been reported.21 The tailoring process used for saphenous vein graft is not required because its size is compatible with that of the SVC. Cryopreserved aortic homograft also may be a good alternative22 because it has a large caliber and low thrombogenicity. Aortic arch homograft can be used as a natural branched graft for the reconstruction of both brachiocephalic veins.22

Surgical Technique of Resection and Reconstruction of the SVC and Right Atrium

A median sternotomy is performed. The pericardium is opened in the midline, and the mediastinum is inspected to rule out unresectable tumor. The right atrium and SVC are exposed (Fig. 140-3). The left and right brachiocephalic veins are also exposed and taped, if necessary. After adequate heparinization, the ascending aorta, SVC, and inferior vena cava are cannulated as described earlier, after which CPB is initiated. After both venae cavae are snared with a tourniquet, the cardiotomy suction tube is placed in the right atrium (Fig. 140-4). The SVC and right atrium are resected with adequate margins from the edge of tumor. When the atrial wall defect is large, reconstruction with an autologous or bovine pericardial patch is required (Fig. 140-5). Otherwise, direct closure can be performed. After reconstruction of the right atrium, the selected graft is anastomosed to the cavoatrial junction of the right atrium with continuous 5-0 polypropylene sutures. The distal anastomosis is performed with continuous 5-0 polypropylene sutures. The azygos vein is closed with continuous 6-0 polypropylene sutures. The snares are released, and the cardiotomy suction tube is removed from the right atrium. The patient is weaned from CPB, heparinization is reversed with protamine, and all cannulas are removed. Temporary atrial and ventricular pacing wires should be placed when the heart is manipulated because temporary or permanent dysrhythmia requiring pacing could occur after surgery, and placement of transvenous pacing leads should be avoided in the immediate postoperative period. Chest tubes are placed, and the chest is closed in standard fashion.

Figure 140-3.

 

Exposure of right atrium and SVC before resection and reconstruction.

 

Figure 140-4.

 

Operative setup for cardiopulmonary bypass.

 

Figure 140-5.

 

Large atrial wall defects are reconstructed with autologous or bovine pericardial patch. The SVC is reconstructed with a ringed ePTFE graft that is anastomosed to the cavoatrial junction of the right atrium.

POSTOPERATIVE MANAGEMENT

The postoperative management of patients undergoing this procedure is routine, with the exception of several additional concerns related to resection and reconstruction of the SVC. After the procedure, one should be able to observe immediate relief of the SVC syndrome. If this is not the case, complications such as graft kinking or thrombosis should be suspected, and diagnostic venography or transesophageal echocardiography should be considered. If kinking of the graft or thrombosis is diagnosed, reoperative or endovascular intervention may be necessary. Placement of an IV catheter in the reconstructed SVC should be avoided in the immediate postoperative period because of the potential risk of thrombosis and anastomotic leakage. Graft thrombosis precipitated by insertion of a central venous catheter 14 months after surgery has been reported.16

To avoid early graft thrombosis in patients with a prosthetic graft, anticoagulation is usually initiated as soon as the absence of postoperative hemorrhage is confirmed.23–25 Unfractionated or low-molecular-weight heparin is started and subsequently replaced by oral warfarin. Anticoagulation is not required for biologic grafts, but temporary use may have some benefit for improved patency of biologic grafts. Aspirin may be a good alternative for biologic grafts.20 The decision should be made based on graft material, as well as the patient's thrombotic and hemorrhagic risks.

Bleeding from reconstruction sites is another complication related to the SVC procedure. It is monitored and managed in the same way as any postoperative hemorrhage. When the sinus node is manipulated, sick sinus syndrome may occur, which requires a temporary or permanent pacemaker. We usually leave temporary pacing leads in place for at least 3 days and remove them unless there is dysrhythmia requiring a pacemaker.

RESULTS

The operative mortality and morbidity of the resection and reconstruction of the SVC depend on the primary surgery rather than on the SVC procedure per se. Long-term outcomes of the procedure for malignant disease largely depend on oncologic consequences. Since resection and reconstruction of the SVC for benign disease are rare (anatomic bypass without resection is more common), there have been no systematic case series reports. In two case series (n = 16 and 29, respectively) where the SVC was reconstructed (anatomic bypass) for benign disease, the operative mortality was zero.19,20

For malignant disease, the operative mortality of resection of the primary tumor and SVC ranges from 0% to 22%.16,23–30 Long-term outcomes vary by the pathology and stage of malignancy. Lung carcinomas generally have inferior long-term survival to mediastinal tumors.16,26 Suzuki and colleagues reported a significant difference in long-term survival after surgery between cases involving SVC invaded by a primary lung carcinoma and SVC invaded by metastatic nodes (5-year survival rates 6.6% versus 36%, respectively).27

Graft Patency

When the SVC and its tributaries are reconstructed with tube grafts, graft patency is an important outcome. Early graft occlusion is caused by graft kinking or thrombosis, and late graft occlusion is caused by thrombosis, fibrosing mediastinitis, extrinsic compression, or invasion of the recurrent tumor. Graft occlusion usually leads to primary or recurrent SVC syndrome. In such cases, secondary surgical or endovascular intervention is necessary and effective.31 In practice, graft patency is inferred by freedom from symptoms of the SVC syndrome in most patients. Radiographic documentation of graft patency is rare in asymptomatic patients. Some studies have reported graft patency demonstrated with venography, CT scan, or some other diagnostic imaging. However, for malignant disease, the patency rate might be overestimated by cases censored for earlier death.

Doty and colleagues reported 16 cases of SVC reconstruction with spiral saphenous vein grafts for benign disease.20 One graft was occluded 4 days after surgery and was repaired surgically. The patient has been asymptomatic for 14 years after reoperation. Long-term follow-up (median 10.9 months) yielded two grafts that were thrombosed at 5 months and 1 year after surgery, respectively. The other patients have been asymptomatic for years.20 Kalra and colleagues reported 29 cases of SVC reconstruction with various grafts for benign disease.19 Spiral saphenous vein graft was used in 20 patients, and 2 of them had a bifurcated graft. Four patients had femoral vein graft, six had ePTFE graft, and one had allograft. Three ePTFE and two bifurcated grafts were occluded in the early postoperative period. Long-term follow-up (mean 5.6 years) yielded 17 secondary interventions performed for 9 grafts: 14 endovascular and 3 surgical interventions. One-year, three-year, and five-year patency rates were 63%, 53%, and 53%, respectively. Patency rates were significantly higher for spiral saphenous vein grafts compared with ePTFE grafts (67% versus 50% at 1 year, 67% versus 17% at 4 years).19

Magnan and colleagues reported 10 cases of resection and reconstruction of the SVC with ePTFE grafts. Nine patients had malignant and one had benign disease. All grafts were patent on venography or CT scan in the immediate postoperative period. No patient had recurrent SVC syndrome over a mean of 17 months of follow-up.23 Dartevelle and colleagues reported 22 ePTFE graft cases and showed 92% patency rate (24 of 26 grafts) over a mean of 23 months of follow-up. One occlusion occurred within 1 month of surgery, and the other occurred 14 months after surgery.16

Shintani and colleagues reported long-term graft patency of various types of SVC reconstructions with ePTFE grafts for malignant disease. From their radiographic follow-up (median 33 months) of 26 grafts in 18 patients, they showed that reconstruction of the left brachiocephalic vein alone results in more frequent incidence of graft occlusion compared with that of the right brachiocephalic vein alone or both brachiocephalic veins. They also recommended two separate grafts for reconstruction of the both brachiocephalic veins rather than a Y-graft.24 The patency of biologic grafts in malignant disease has not been systematically reported.

SUMMARY

Resection and reconstruction of the SVC is a feasible and effective procedure for selected patients. Less invasive procedures, such as bypass and endovascular technique, should be considered when symptom relief is the solitary goal of surgery. Preoperative assessment of tumor resectability, extent of involvement of the SVC and cardiac component, and collateral circulation is essential to formulating a reasonable surgical plan. The need for the SVC resection per se is not a contraindication for surgery. CPB is a useful adjunct to performing a safe procedure when the cardiac apparatus is involved. Biologic grafts seem preferable in terms of graft patency. However, ePTFE grafts are used most commonly in malignant disease and have been shown to have excellent graft patency.

CASE HISTORIES

Two cases have been selected. The first illustrates resection and reconstruction of the SVC for a malignant mediastinal tumor found invading the SVC and both atria. The second illustrates the emergency repair of a ruptured SVC caused by endovascular intervention.

Case 1

A 14-year-old boy presented with a 1-year history of persistent cough. Chest x-ray revealed a large anterior mediastinal mass, which was confirmed by chest CT scan to involve the SVC and both atria. The patient had a CT-guided biopsy and was diagnosed with Ewing's sarcoma. He subsequently underwent chemotherapy. After completing the chemotherapy course, he was referred to our hospital for further evaluation. MRI revealed a mediastinal tumor extending from the hilum of the right lung into the left atrium, the right atrium, and the SVC that was deemed to be curable. The patient was scheduled to have a right pneumonectomy with resection and reconstruction of both atria and the SVC.

A median sternotomy was performed. The pericardium was opened in the midline, and thorough inspection revealed a good chance of probable total resection. After heparinization, the ascending aorta and both venae cavae were cannulated, and CPB was instituted. At the appropriate flow rates, the patient was cooled down to 28°C. The aorta was cross-clamped, and the heart was protected by cold hyperkalemic blood cardioplegia delivered through the antegrade route. The tumor involved the lower (or proximal) third of the superior vena cava and the free wall of the right atrium down to the level of the septum, with extension along the right superior pulmonary veins into the left atrium. Both venae cavae were snared. The lower third of the SVC was transected just below the level of the SVC cannula. The right atrium was resected with good, clean margins away from the tumor mass along with the interatrial septum and across the wall of the left atrium, taking a wide margin around the entrance of the superior pulmonary veins. Subsequently, the right pneumonectomy was performed. The left atrium was reconstructed with glutaraldehyde-treated bovine pericardium by using running 4-0 polypropylene sutures. The interatrial septum and the defect of the right atrium also were reconstructed with glutaraldehyde-treated bovine pericardium by using running 4-0 polypropylene sutures. The SVC was reconstructed with a bovine pericardial tube that was fashioned from a piece of pericardium and closed along its length with a double row of metal staples. The distal end of the tube graft was anastomosed in an end-to-end fashion to the remnant of the SVC by using running 5-0 polypropylene sutures. The proximal end of the tube graft was anastomosed to a transverse opening in the right atrial pericardial patch in an end-to-end fashion by using running 4-0 polypropylene sutures. The aorta was unclamped, and the patient was weaned off CPB without difficulty. Hemodynamic stability was achieved. The cannulas were removed. Heparin was reversed with protamine. Adequate hemostasis was achieved. Atrial and ventricular temporary pacing wires and chest tubes were placed. The chest was closed.

Postoperatively, the patient experienced respiratory compromise (requiring reintubation) and supraventricular tachycardia. Both conditions were treated appropriately. The patient recovered well and was discharged to home on postoperative day 14.

Case 2

A 56-year-old woman developed swelling of the left arm, left neck, and face after radiotherapy for advanced breast cancer. The imaging studies revealed SVC obstruction at the level of the main pulmonary artery and stenosis of the left brachiocephalic vein. She was diagnosed with postirradiation SVC syndrome and initially referred to the thoracic surgery service. After it was determined that her disease had metastasized, she was deemed to be a poor surgical candidate. Consequently, she elected to undergo endovascular stenting, which resulted in perforation of the SVC and left brachiocephalic vein. The patient was emergently transferred to the OR after cardiopulmonary resuscitation.

During urgent preparation and draping, heparin was administered. A median sternotomy was performed, and the pericardium was opened. The heart was found to be totally empty and in ventricular fibrillation. There was prominent clot around the left brachiocephalic vein and the SVC. The ascending aorta was cannulated, and blood product and fluid were transfused through the aortic cannula to replace the blood volume. The right atrium was cannulated, and CPB was instituted. At the appropriate flow rates, the patient was cooled down to 18°C. We chose deep hypothermic circulatory arrest because the tears in her veins were too large for temporary bypass or intraluminal shunt. During the cooling period, a large tear in the left brachiocephalic vein was inspected. A ruptured balloon was retrieved from that location. The tear was repaired primarily with continuous 5-0 polypropylene sutures. When the desired temperature was reached, the second tear of the SVC was repaired with 4-0 polypropylene sutures under circulatory arrest. The patient then was rewarmed, and the heart resumed spontaneous rhythm. The patient was weaned off CPB with inotropic support. The patient tolerated the procedure and was transferred to the ICU.

EDITOR'S COMMENT

Contemporary surgical approaches to the repair and replacement of the vena cava suggest more general lessons regarding operability; namely, evolving surgical techniques may offer options for patients whose disease was previously considered "inoperable." Importantly, this reassessment must be made in the context of the individual patient's disease process and physiologic reserve.

–SJM

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