Asian Cardiovasc Thorac Ann 2007;15:345-347
© 2007 Asia Publishing EXchange Ltd
Superior Vena Cava Reconstruction with Homograft Conduit under Circulatory Arrest
Balakrishnan Mahesh, FRCS,
Chandana Ratnatunga, FRCS (CTh)
Division of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
For reprint information contact: Balakrishnan Mahesh, FRCS Tel: 44 7951 033 090 Fax: 44 1895 828 900 Email: b.mahesh{at}imperial.ac.uk, Transplant Immunology, Heart Science Center, Harefield Hospital, Middlesex UB9 6JH, United Kingdom.
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ABSTRACT
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Superior vena cava obstruction may be due to benign or malignant causes. This may be treated surgically by using autologous saphenous vein grafts, autologous pericardial patches cut and reconstituted as tubes, expanded polytetrafluoroethylene grafts, or percutaneously by balloon dilatation and stenting procedures. We report a case of superior vena cava obstruction in which the obstructed segment was bypassed using a tube constructed from aortic and pulmonary homograft conduits, under hypothermic circulatory arrest without using jugulo-atrial shunts, leaving the obstructed segment in situ.
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INTRODUCTION
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Occlusion of the superior vena cava (SVC) may result from malignant or benign pathology, or may be iatrogenic.1–3 Endovascular intervention has become the treatment of choice for malignant SVC occlusions.1 Surgery, in contrast, has been the mainstay of treatment for benign SVC occlusions.1–5 We report a case of SVC obstruction in which the obstructed segment was bypassed under hypothermic circulatory arrest without using jugulo-atrial shunts, by a tube constructed from aortic and pulmonary homografts.
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CASE REPORT
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A 46-year-old lady presented with recurrent headaches. She had undergone pacemaker insertion for sick sinus syndrome 27 years previously. Eighteen years ago, she presented with SVC obstruction due to pacing wires and was anticoagulated with coumadin. Eight years ago, attempted revision of the pacemaker failed due to persistent SVC obstruction. The old pacemaker was removed leaving the wires in situ, and a new epicardial pacemaker system was inserted.
On examination, the patient had evidence of SVC obstruction with dilated veins over her upper chest wall. There was no papilledema. Current venogram investigation revealed complete occlusion of the left subclavian, innominate, and both internal jugular veins, with only the right subclavian vein remaining patent. The pacemaker wires were in situ. She subsequently became pyrexial with blood cultures positive for coagulase-negative Staphylococcus, and intravenous broad-spectrum antibiotics were commenced. Surgery was therefore indicated for relief of SVC obstruction and removal of the infected pacing wires, and was performed two weeks later.
The procedure was performed through a median sternotomy under intravenous antibiotic cover. There was complete fibrosis of the innominate vein, both internal jugular veins, and the SVC. The right subclavian vein was patent. This was approached by a right T-extension through the manubrium. Cardiopulmonary bypass was achieved by ascending aortic and right atrial cannulation, with systemic cooling to 18°C. During cooling, a tube was constructed by end-to-end anastomosis of aortic and pulmonary homografts, using 5-0 prolene, after excising the valves and ligating the coronary ostia. At 18°C, the circulation was arrested and drained. The right subclavian vein was opened close to its junction with the thrombosed jugular vein, and confirmed to be patent by passage of 28F–32F Hegar’s dilators. End-to-side anastomosis of the homograft conduit was performed onto this venotomy site, using 5-0 prolene. The right atrium was opened just beyond entry of the SVC. The old pacing wires in the right atrium were cut as high as possible. End-to-side anastomosis of the homograft conduit was performed to the atriotomy, using 5-0 prolene. The completed reconstruction with the homografts is shown in Figure 1
. The obstructed segment of the SVC and innominate vein was left in situ and not resected. Circulation was recommenced and the patient was rewarmed. After confirmation of patency and flow in the homograft conduit by palpation, cardiopulmonary bypass was discontinued by standard methods. A new epicardial pacemaker system was inserted.
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Figure 1. Completed reconstruction of the superior vena cava, showing the combined aortic and pulmonary homograft conduit anastomosed to the right subclavian vein superiorly and right atrium inferiorly.
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Postoperatively, the patient made an excellent recovery, and was discharged home after four weeks of intravenous antibiotics, on oral dicoumarol to maintain an INR of 2–3. At 6 months, she was asymptomatic, on oral dicoumarol, with confirmation of a patent homograft conduit by venogram.
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DISCUSSION
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Partial or complete occlusion of the SVC may be due to malignancy,2,3 non-malignant diseases,2 or iatrogenic causes including long-term catheters and pacing electrodes.1,2 Successful surgical treatment must result in satisfactory drainage of the upper third of the body via direct rather than multiple collateral channels. In malignant SVC occlusion, percutaneous transluminal angioplasty (PTA) and stenting have become the treatments of choice, due to limited life-expectancy.1
Benign SVC obstruction has also been treated by percutaneous balloon-dilatation procedures, supplemented by stents.1,6 Surgery remains the mainstay of treatment for benign SVC occlusions.1–5 Operative reconstruction of the obstructed SVC is superior to percutaneous intervention in the long-term, with PTA and stenting having encouraging early results, but requiring multiple interventions to maintain even short-term patency.1,6
A number of options are available to reconstruct a drainage channel. Favored options include autologous pericardium, fashioned as a patch or a tube, depending upon the length of segment of SVC to be bypassed,2,3 or autologous saphenous vein, cut longitudinally and sutured spirally around a 40-French polytetrafluoroethylene (PTFE) stent to provide a 12 mm diameter tube.5 The former has the advantage of ease of preparation.2 Expanded PTFE (ePTFE) tube grafts,4 umbilical veins and Dacron grafts7 have also been used. Although autologous saphenous vein grafts are superior to ePTFE tube grafts,8 no single procedure is a clear-cut success, with reports of longer-term problems with patency, requiring several percutaneous graft dilatation and stenting procedures.1
We have described a useful technique wherein homograft conduits were used to bypass the obstructed brachiocephalic veins and the SVC. Advantages of such conduits are that they are of larger diameter with an arterial wall structure and are successful in the arterial setting. They are probably less prone to thrombosis and may not need long-term anticoagulation, with its concomitant hazards.
Prolonged clamping of the SVC during reconstruction in the absence of collaterals can acutely compromise the venous drainage of the upper third of the body and lead to acute cerebral edema with potentially fatal neurological complications. This has been circumvented by development of venovenous jugulo-atrial shunts to bypass the obstructed segment.2,3
Hypothermic circulatory arrest at 18°C offers an alternative method for avoiding potentially fatal neurological complications associated with acute cerebral edema. This technique also removes the need for jugulo-atrial shunts, which would have been impossible to place in our case due to thrombosis of both internal jugular veins, with only the right subclavian vein remaining patent and possibly being the sole drainage channel for cerebral circulation through collaterals. It provided excellent operative conditions which allowed rapid performance of veno-conduit and the conduit-atrial anastomoses. We are fortunate in having a homograft facility in our institution with ready availability of material for surgery. Although access to homografts may be more difficult for others, this technique should be considered to bypass the SVC in complex cases.
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ACKNOWLEDGMENTS
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We thank Datascope Medical Co. Ltd., Huntingdon, UK, for their valuable support and funding.
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REFERENCES
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ABSTRACT
INTRODUCTION
