Original Communications Bypass of superior vena cava Six years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease Ten patients had operations for obstruction of the superior vena cava (SVC) with SVC syndrome. Four patients had fibrosing mediastinitis and six had bronchogenic carcinoma. A composite spiral vein graft was placed between the left jugular-subclavian vein and the right atrium to bypass the completely occluded SVC. The graft was constructed from the patient's own saphenous vein, which was split longitudinally and wrapped around a stent in spiral fashion. The edges of the vein were sutured together to form a large autogenous conduit. All patients were immediately relieved of SVC obstructive symptoms and signs. All grafts were patent at 7 days to 18 months, as determined by conventional or radionuclide venography or contrast-enhanced computerized axial tomography. The fact that SVC syndrome has not returned in any patient implies long-term patency. All patients with benign disease continue asymptomatic 3 months to 6 years after operation and have returned to gainful employment. All patients with SVC obstruction resulting from cancer have died 1 to 21 months (mean 10.7 months) postoperatively. Spiral vein bypass graft provides effective treatment for SVC obstruction with immediate and long-term relief of SVC syndrome. Donald B. Doty, M.D., Iowa City, Iowa J\.eplacement of the superior vena cava with a com- posite spiral vein graft was first reported in an experi- mental setting by Chiu, Terzis, and MacRae 1 in 1974. Clinical application of this principle was reported by Doty and Baker 2 in 1976. Experience with a total often patients having bypass of the superior vena cava ob- structed by benign and malignant disease processes has occurred since the initial successful operation in a pa- tient with obstruction of the vena cava due to granulo- matous sclerosing mediastinitis. The details of the use of spiral vein bypass grafts to relieve the signs and symptoms of superior vena cava syndrome are pre- sented in this paper. From The University of Iowa Hospitals and Clinics, Iowa City, Iowa. Read at the Seventh Annual Meeting of The Samson Thoracic Surgi- cal Society, Maui, Hawaii, June 24-27, 1981. Address for reprints: Donald B. Doty, M.D., Division of Thoracic and Cardiovascular Surgery, Department of Surgery, The Uni- versity of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. Patients and methods Ten patients had an operation to bypass the superior vena cava at The University of Iowa Hospitals between January, 1975, and February, 1981. There were nine men and one woman ranging in age from 30 to 64 years. Tissue diagnosis was obtained in each case, with four patients having obstruction of the superior vena cava owing to a benign process and six having carci- noma involving the superior vena cava and mediasti- num. Clinical features are presented in Tables I and II. The most prominent symptoms which became indica- tions for operation were near syncope in two patients, constant headache and difficulty with mentation sug- gesting cerebral edema in four patients, and hoarseness or other signs of laryngeal edema in four patients. Work-up included bilateral arm contrast venography in all patients to determine location and character of su- perior vena cava obstruction, extent of patency and distention of innominate-subclavian-jugular veins, and adequacy of collateral venous circulation (Fig. 1). Pa- 326 0022-5223/82/030326+ 13$01.30/0 © 1982 The C. V. Mosby Co.
Bypass of superior vena cava
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Bypass of superior vena cavaBypass of superior vena cava
Six years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease
Ten patients had operations for obstruction of the superior vena cava (SVC) with SVC syndrome. Four patients had fibrosing mediastinitis and six had bronchogenic carcinoma. A composite spiral vein graft was placed between the left jugular-subclavian vein and the right atrium to bypass the completely occluded SVC. The graft was constructed from the patient's own saphenous vein, which was split longitudinally and wrapped around a stent in spiral fashion. The edges of the vein were sutured together to form a large autogenous conduit. All patients were immediately relieved of SVC obstructive symptoms and signs. All grafts were patent at 7 days to 18 months, as determined by conventional or radionuclide venography or contrast-enhanced computerized axial tomography. The fact that SVC syndrome has not returned in any patient implies long-term patency. All patients with benign disease continue asymptomatic 3 months to 6 years after operation and have returned to gainful employment. All patients with SVC obstruction resulting from cancer have died 1 to 21 months (mean 10.7 months) postoperatively. Spiral vein bypass graft provides effective treatment for SVC obstruction with immediate and long-term relief of SVC syndrome.
Donald B. Doty, M.D., Iowa City, Iowa
J\.eplacement of the superior vena cava with a com- posite spiral vein graft was first reported in an experi- mental setting by Chiu, Terzis, and MacRae1 in 1974. Clinical application of this principle was reported by Doty and Baker2 in 1976. Experience with a total often patients having bypass of the superior vena cava ob- structed by benign and malignant disease processes has occurred since the initial successful operation in a pa- tient with obstruction of the vena cava due to granulo- matous sclerosing mediastinitis. The details of the use of spiral vein bypass grafts to relieve the signs and symptoms of superior vena cava syndrome are pre- sented in this paper.
From The University of Iowa Hospitals and Clinics, Iowa City, Iowa. Read at the Seventh Annual Meeting of The Samson Thoracic Surgi-
cal Society, Maui, Hawaii, June 24-27, 1981. Address for reprints: Donald B. Doty, M.D., Division of Thoracic
and Cardiovascular Surgery, Department of Surgery, The Uni- versity of Iowa Hospitals and Clinics, Iowa City, Iowa 52242.
Patients and methods
Ten patients had an operation to bypass the superior vena cava at The University of Iowa Hospitals between January, 1975, and February, 1981. There were nine men and one woman ranging in age from 30 to 64 years. Tissue diagnosis was obtained in each case, with four patients having obstruction of the superior vena cava owing to a benign process and six having carci- noma involving the superior vena cava and mediasti- num. Clinical features are presented in Tables I and II. The most prominent symptoms which became indica- tions for operation were near syncope in two patients, constant headache and difficulty with mentation sug- gesting cerebral edema in four patients, and hoarseness or other signs of laryngeal edema in four patients. Work-up included bilateral arm contrast venography in all patients to determine location and character of su- perior vena cava obstruction, extent of patency and distention of innominate-subclavian-jugular veins, and adequacy of collateral venous circulation (Fig. 1). Pa-
326 0022-5223/82/030326+ 13$01.30/0 © 1982 The C. V. Mosby Co.
Volume 83 Number 3 March, 1982
Bypass of superior vena cava 3 27
Table I. Bypass of superior vena cava obstructed by benign disease
Case No.
Fibrosing mediastinitis
Sclerosing mediastinitis
Special circumstances during operation
Prior bypass, right axillary to azygos vein with aortic homo- graft
Bypass, left internal jugular vein to right atrial appendage
Other treatment
76
49
36
3
Results
Asymptomatic
Asymptomatic
Asymptomatic
Asymptomatic
Table II. Bypass of superior vena cava obstructed by malignant disease
Case No.
Special circumstances during operation
Right atrial appendage involved in tumor, bypass to right atrium near IVC
Required thrombectomy of innominate and left internal jugular veins
Other treatment
5,000 rads
5,000 rads
5,000 rads
S VC syndrome relieved; died 4-25-78, carcino- matosis
SVC syndrome relieved; died 1-27-79, aldoste- rone effect of tumor, pulmonary embolus, and ileofemoral thrombosis
SVC syndrome relieved; died 4-8-81, carcino- matosis
SVC syndrome relieved; died 12-8-80, carcino- matosis
Legend: IVC, Inferior vena cava. SVC, Superior vena cava.
tients with incomplete superior vena cava obstruction or extrinsic compression deformity were treated by standard measures other than surgical therapy along with those patients having superior vena cava obstruc- tion caudal to a patent azygos vein or other signs of adequate collateral circulation so that upper compart- ment veins were not distended. Some patients were studied by isotope venography before operation. All patients had either contrast or isotope venography to confirm graft patency during the first week after opera- tion. Cervical ultrasound or computerized axial tomog- raphy was used in the work-up or follow-up in selected
cases. Directional Doppler ultrasound examination was also performed to determine relative velocity in the internal jugular veins as an indication of graft patency. A standard operation was performed in each patient with construction of a composite spiral graft from the patient's own saphenous vein. The graft was used to connect the innominate or left internal jugular vein to the right atrium. Graft size ranged from 28 Fr. (9 mm diameter) to 40 Fr. (13 mm diameter). All of the pa- tients received aspirin and dipyridamole (Persantine) for 6 months postoperatively with discontinuation of only dipyridamole at that point. Continuous aspirin
3 2 8 Doty The Journal of
Thoracic and Cardiovascular Surgery
Fig. 1. Contrast venogram (subtraction) demonstrating complete obstruction of the superior vena cava with propagation of thrombus (T) into the innominate vein and dilation of veins with valvular incompetence allowing left internal jugular vein reflux (arrow). Thoracic venous collateral system is inadequate. A portion of the innominate vein on the left remains patent and available for bypass graft.
therapy, 650 mg/day, has been advised. Follow-up has been obtained in all patients by personal contact or examination.
The operation
A midsternal incision is made. Chest wall collateral circulation is controlled by electrocautery. An auto- transfusion device (Cell Saver, Haemonetics Corpora- tion, Natick, Mass.) is helpful in reducing blood replacement requirement. A biopsy specimen of the ob- structing process in the mediastinum is taken. The upper portion of the pericardium is opened in the mid- line to expose the right atrial appendage. The thymic remnant is removed and the innominate vein is com- pletely mobilized. Once feasibility of bypass has been established by assessment of innominate or left internal jugular vein patency, the greater saphenous vein may be exposed by incision of the skin of the thigh over the vein from the groin to the knee. The diameter of the innominate or jugular vein and the length to the right atrial appendage are measured. The diameter of the innominate vein is divided by the average diameter of the saphenous vein. This ratio multiplied by the length from innominate vein to right atrium determines the length of saphenous vein required to construct a com- posite spiral graft of sufficient length and of the same diameter as the innominate vein. For example, if the diameter of the innominate vein is 12 mm and the aver-
age diameter of the saphenous vein is 4 mm, three times the length of saphenous vein will be required to bridge the distance between the innominate vein and right atrial appendage. In practice, excision of saphe- nous vein from groin to knee is usually sufficient.
The side branches of the saphenous vein are ligated and divided. The vein is excised from the leg and gently distended with heparinized electrolyte solution. Any unligated branches are controlled. The vein is opened longitudinally through its entire length. An Ar- gyle thoracostomy catheter of the same diameter of the innominate vein is selected to form a stent over which the composite spiral graft will be constructed. The sa- phenous vein is wrapped around the stent in spiral fash- ion, the endothelial surface placed against the stent. The graft edges are secured at the first complete wrap by suture to allow tension to be maintained on the sa- phenous vein for maximum length as it is spiralled around the catheter. The edges of the graft are secured by suture at the last complete wrap to maintain the configuration. The edges of the saphenous vein are ap- proximated by continuous stitch with 7-0 polypropyl- ene suture. Optical magnification (2.5 power) is used to assure accuracy of the anastomosis and approximation of the endothelial surface. About a 30 minute period is required to prepare the graft.
Heparin, 100 to 300 units/kg, is administered intra- venously to the patient. The innominate vein is ligated
Volume 83 Number 3 March, 1982
Bypass of superior vena cava 3 2 9
as close to the superior vena cava as possible. A soft Fogarty vascular clamp is applied at the jugular- subclavian confluence, and the innominate vein divided so that as much length as possible is preserved. The intima of the innominate vein is inspected to assure that it is normal. Thrombus may be removed which is not adherent, provided the intima of the vein remains nor- mal. Organized thrombus which has become adherent and altered the intimal surface should be removed by completely excising the vein back to normal tissue beyond the thrombosed area. The end of the composite spiral vein graft is trimmed to provide a uniform cir- cumference. The graft is pushed slightly off the end of the stent. An end-to-end anastomosis of the graft to the innominate vein is constructed with continuous stitches of 7-0 polypropylene suture. When the anastomosis is complete, the stent is removed and the graft placed in the mediastinum anterior to the aorta. The entire right atrial appendage is excluded by vascular clamp placed on the right atrium below the base of the appendage. The tip of the appendage is excised and all trabeculae within the appendage are removed to assure an unre- stricted passageway into the atrium. An end-to-end anastomosis of the vein graft to the right atrial append- age is made with 5-0 polypropylene suture (Fig. 2). Prior planning of the orientation of the graft will allow utilization of the naturally occurring bevel of the graft for correct approximation to the atrial appendage. The vascular clamps are removed, protamine administered, and the graft packed for a few minutes to achieve hemostasis. Correct measurement of graft length is es- sential; there is no advantage to excessive length, as hemostasis will not be satisfactory and any angles in the graft will likely be detrimental for patency. The pericardium is left open; wound closure is routine.
Postoperatively, the condition of the patient may temporarily appear worse with more facial and periorbi- tal edema owing to the supine body position with the neck extended during the operation. A 30% to 45% head-up position in bed is optimal. The endotracheal tube should be removed cautiously in case there may be some laryngeal edema. The upper compartment venous system will rapidly decompress so that facial edema will largely disappear within 24 to 48 hours.
Results
All 10 patients having composite spiral vein graft to bypass the superior vena cava have survived the opera- tion and the postoperative period and have been dis- charged from the hospital. Preoperative venography was the most useful diagnostic examination and showed complete occlusion of the superior vena cava in
Fig. 2. Composite spiral saphenous vein bypass graft (arrow) viewed through the midsternal incision. The proximal anas- tomosis to the innominate vein is beneath the sternum on the left. The graft courses across the mediastinum anterior to the aorta (Ao) to join the right atrial appendage (RA).
all cases. The obstruction involved the azygos vein and extended cephalad in the vena cava to involve the innominate-cava junction in all cases, producing sig- nificant distention of the veins in the neck and arms. Patency of the innominate vein or the subclavian-left internal jugular confluence was documented in eight patients; in the other two patients, thrombosis had propagated beyond the thoracic inlet to involve the subclavian-axillary venous system or internal jugular vein on the left side (Fig. 3). In one patient, it was not possible to document left internal jugular vein patency by three attempts at venography. In this case, cervical ultrasound examination demonstrated a patent left in- ternal jugular vein (Fig. 4), which proved adequate for anastomosis to the bypass graft. One patient previously had had a bypass of the right axillary vein to azygos vein with homograft aorta, which had thrombosed. Biopsy of the obstructing process in the right side of the mediastinum provided tissue diagnosis in all cases. In
3 3 0 Doty The Journal of
Thoracic and Cardiovascular Surgery
Fig. 3. Contrast venogram shows that thrombosis of the superior vena cava has propagated into all intrathoracic tributaries. No portion of the innominate vein remains available and any bypass anastomosis must be in the neck above the thoracic inlet.
Fig. 4. Ultrasound image of the long axis of the neck demonstrates patent left internal jugular vein (arrow).
four patients, superior vena cava obstruction was due to a benign process (Table I) and in six patients there was a mediastinal malignancy (carcinoma) (Table II).
The operation was as described in all except three patients. One patient required thrombectomy of the left internal jugular and subclavian veins prior to bypass graft. In this case the thrombus was recent and only moderately adherent to the intima of the vein, so that the thrombus could be removed. Another patient had only the internal jugular vein patent; the sternotomy had to be extended so that an anastomosis could be
performed in the neck above the thoracic inlet. A third patient had involvement of the right atrial appendage with tumor. It was possible, however, to achieve anas- tomosis to the side of the right atrium just above the inferior vena cava. Blood loss was not excessive in any patient, but autotransfusion techniques seemed to be a useful adjunct.
All patients were relieved of symptoms and signs of superior vena cava syndrome within 48 hours after op- eration. In no case did these symptoms or signs return during the follow-up period. Each patient retained
Volume 83 Number 3 March, 1982
Fig. 5. Infrared photograph before operation shows marked subcutaneous venous pattern as well as facial and periorbital edema.
some distention of the external jugular veins, suggest- ing head and neck venous pressure was slightly above normal even though the patients were asymptomatic. Swelling of the arms resolved promptly in the postop- erative period even on the right side, where no direct decompressive procedure was done. Infrared photo- graphs taken of one patient to bring out the superficial vein pattern before and after bypass documented relief of venous distention as well as resolution of facial and arm swelling (Figs. 5 and 6). Superficial veins were prominent only over the right shoulder after operation. Contrast or radionuclide venography documented graft patency during the first week after operation in all cases (Figs. 7 and 8). Late patency at 6 months was docu- mented by contrast venography in the first three cases. Late venograms were not done in other cases, as the symptom-free patients reported accurate clinical follow-up and noninvasive Doppler ultrasound demon- strated differential flow velocity in the internal jugular veins suggesting graft patency. Fig. 9 shows typical
Bypass of superior vena cava 3 3 1
Fig. 6. Infrared photograph after operation shows resolution of venous pattern over left arm, shoulder, and thorax. Venous pattern on the right remains, though less pronounced. Facial and periorbital edema has resolved.
directional Doppler ultrasound examination demon- strating approximately two times the flow velocity in the left internal jugular vein compared to the right side.
Bypass of the superior vena cava was all the therapy necessary for the four patients with obstruction of the superior vena cava due to benign disease. All four have remained completely asymptomatic for periods up to 6 years, results which imply long-term graft patency. All have returned to gainful employment and have good exercise capacity. All can bend or stoop over without symptoms.
All patients with obstruction of the superior vena cava resulting from a malignant process required other therapy aimed at palliation of the primary disease pro- cess. Five of the six received supervoltage radiation to the mediastinum in doses ranging from 3,000 to 6,000 rads. Three of them received chemotherapy; one re- ceived chemotherapy as primary treatment of a small cell carcinoma and the other two were given chemo- therapy later, in an attempt to palliate extrathoracic
3 3 2 Doty The Journal of
Thoracic and Cardiovascular Surgery
Fig. 7. Contrast venography after operation shows patent composite spiral saphenous vein bypass graft between in- nominate vein and right atrium and satisfactory resolution of venous distention. Collateral venous channels remain on the right.
metastasis. Graft patency has been uniform despite these other modes of therapy. The patients tolerated palliative treatments very well in the absence of the distress of superior vena cava syndrome. Satisfactory palliation of 12 months or greater was achieved in four of the six patients. The four patients surviving a year or more were quite comfortable until the last few months. Three of the four returned to their usual employment for several months after palliative therapy was com- pleted. One of them worked for over 15 months and survived for 21 months with a patent graft documented by computerized axial tomography at 18 months (Fig. 10). There were no signs of superior vena cava ob- struction, but the patient eventually died of extensive cerebral, mediastinal, retroperitoneal, and hepatic me- tastases. Two patients died early after operation. One died about 3 weeks after operation at another hospital because of apparent pulmonary embolus and iliofemoral venous thrombosis. This patient was very debilitated at the time of operation, having extensive mediastinal dis- ease and marked aldosterone endocrine effects from the small cell tumor. Another patient died at 5 months of extensive metastasis from anaplastic carcinoma. The mean survival time was 10.7 months. The patients died either at home or in other hospitals and autopsy was done in only one of them (Case 6, Table II). The com-
"."•.'-V'.'fci
Fig. 8. Radionuclide venogram after operation demonstrates patent bypass graft filling right heart from left arm venous injection.
posite spiral saphenous vein graft was shown to be patent 13 months after operation and after the patient received 5,000 rads to the mediastinum. The graft ap- peared to have smooth, glistening endothelium (Fig. 11) and histologic sections revealed normal morphology of the saphenous vein (Fig. 12).
Discussion
Lokich and Goodman3 reported that the major pit- falls in management of superior vena cava obstruction relate to attempts to establish the site of obstruction and to obtain specific tissue diagnosis. In their experience, venography, venous pressure manometry, bronchos- copy , and cervicomediastinal explorations may lead to life-threatening complications such as respiratory ob- struction, aspiration, and hemorrhage. They recom- mended immediate therapeutic intervention to relieve caval obstruction symptoms and later tissue biopsy, since the disease process is malignant in over 90% of cases. Shimm, Logue, and Rigsby,4 to the contrary, found that invasive diagnostic procedures can be car- ried out effectively and safely. They showed that seven of 18 patients presenting with superior vena cava syn- drome as the initial manifestation of disease had small cell carcinoma, which currently appears to be best treated by combination chemotherapy techniques. It should be noted, however, that despite complete work-up, which included exploration of the mediasti- num or thorax in some cases, two of the 18 remained without histologic diagnosis. Recent reviews of su-
Volume 83
Number 3
March,…
Six years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease
Ten patients had operations for obstruction of the superior vena cava (SVC) with SVC syndrome. Four patients had fibrosing mediastinitis and six had bronchogenic carcinoma. A composite spiral vein graft was placed between the left jugular-subclavian vein and the right atrium to bypass the completely occluded SVC. The graft was constructed from the patient's own saphenous vein, which was split longitudinally and wrapped around a stent in spiral fashion. The edges of the vein were sutured together to form a large autogenous conduit. All patients were immediately relieved of SVC obstructive symptoms and signs. All grafts were patent at 7 days to 18 months, as determined by conventional or radionuclide venography or contrast-enhanced computerized axial tomography. The fact that SVC syndrome has not returned in any patient implies long-term patency. All patients with benign disease continue asymptomatic 3 months to 6 years after operation and have returned to gainful employment. All patients with SVC obstruction resulting from cancer have died 1 to 21 months (mean 10.7 months) postoperatively. Spiral vein bypass graft provides effective treatment for SVC obstruction with immediate and long-term relief of SVC syndrome.
Donald B. Doty, M.D., Iowa City, Iowa
J\.eplacement of the superior vena cava with a com- posite spiral vein graft was first reported in an experi- mental setting by Chiu, Terzis, and MacRae1 in 1974. Clinical application of this principle was reported by Doty and Baker2 in 1976. Experience with a total often patients having bypass of the superior vena cava ob- structed by benign and malignant disease processes has occurred since the initial successful operation in a pa- tient with obstruction of the vena cava due to granulo- matous sclerosing mediastinitis. The details of the use of spiral vein bypass grafts to relieve the signs and symptoms of superior vena cava syndrome are pre- sented in this paper.
From The University of Iowa Hospitals and Clinics, Iowa City, Iowa. Read at the Seventh Annual Meeting of The Samson Thoracic Surgi-
cal Society, Maui, Hawaii, June 24-27, 1981. Address for reprints: Donald B. Doty, M.D., Division of Thoracic
and Cardiovascular Surgery, Department of Surgery, The Uni- versity of Iowa Hospitals and Clinics, Iowa City, Iowa 52242.
Patients and methods
Ten patients had an operation to bypass the superior vena cava at The University of Iowa Hospitals between January, 1975, and February, 1981. There were nine men and one woman ranging in age from 30 to 64 years. Tissue diagnosis was obtained in each case, with four patients having obstruction of the superior vena cava owing to a benign process and six having carci- noma involving the superior vena cava and mediasti- num. Clinical features are presented in Tables I and II. The most prominent symptoms which became indica- tions for operation were near syncope in two patients, constant headache and difficulty with mentation sug- gesting cerebral edema in four patients, and hoarseness or other signs of laryngeal edema in four patients. Work-up included bilateral arm contrast venography in all patients to determine location and character of su- perior vena cava obstruction, extent of patency and distention of innominate-subclavian-jugular veins, and adequacy of collateral venous circulation (Fig. 1). Pa-
326 0022-5223/82/030326+ 13$01.30/0 © 1982 The C. V. Mosby Co.
Volume 83 Number 3 March, 1982
Bypass of superior vena cava 3 27
Table I. Bypass of superior vena cava obstructed by benign disease
Case No.
Fibrosing mediastinitis
Sclerosing mediastinitis
Special circumstances during operation
Prior bypass, right axillary to azygos vein with aortic homo- graft
Bypass, left internal jugular vein to right atrial appendage
Other treatment
76
49
36
3
Results
Asymptomatic
Asymptomatic
Asymptomatic
Asymptomatic
Table II. Bypass of superior vena cava obstructed by malignant disease
Case No.
Special circumstances during operation
Right atrial appendage involved in tumor, bypass to right atrium near IVC
Required thrombectomy of innominate and left internal jugular veins
Other treatment
5,000 rads
5,000 rads
5,000 rads
S VC syndrome relieved; died 4-25-78, carcino- matosis
SVC syndrome relieved; died 1-27-79, aldoste- rone effect of tumor, pulmonary embolus, and ileofemoral thrombosis
SVC syndrome relieved; died 4-8-81, carcino- matosis
SVC syndrome relieved; died 12-8-80, carcino- matosis
Legend: IVC, Inferior vena cava. SVC, Superior vena cava.
tients with incomplete superior vena cava obstruction or extrinsic compression deformity were treated by standard measures other than surgical therapy along with those patients having superior vena cava obstruc- tion caudal to a patent azygos vein or other signs of adequate collateral circulation so that upper compart- ment veins were not distended. Some patients were studied by isotope venography before operation. All patients had either contrast or isotope venography to confirm graft patency during the first week after opera- tion. Cervical ultrasound or computerized axial tomog- raphy was used in the work-up or follow-up in selected
cases. Directional Doppler ultrasound examination was also performed to determine relative velocity in the internal jugular veins as an indication of graft patency. A standard operation was performed in each patient with construction of a composite spiral graft from the patient's own saphenous vein. The graft was used to connect the innominate or left internal jugular vein to the right atrium. Graft size ranged from 28 Fr. (9 mm diameter) to 40 Fr. (13 mm diameter). All of the pa- tients received aspirin and dipyridamole (Persantine) for 6 months postoperatively with discontinuation of only dipyridamole at that point. Continuous aspirin
3 2 8 Doty The Journal of
Thoracic and Cardiovascular Surgery
Fig. 1. Contrast venogram (subtraction) demonstrating complete obstruction of the superior vena cava with propagation of thrombus (T) into the innominate vein and dilation of veins with valvular incompetence allowing left internal jugular vein reflux (arrow). Thoracic venous collateral system is inadequate. A portion of the innominate vein on the left remains patent and available for bypass graft.
therapy, 650 mg/day, has been advised. Follow-up has been obtained in all patients by personal contact or examination.
The operation
A midsternal incision is made. Chest wall collateral circulation is controlled by electrocautery. An auto- transfusion device (Cell Saver, Haemonetics Corpora- tion, Natick, Mass.) is helpful in reducing blood replacement requirement. A biopsy specimen of the ob- structing process in the mediastinum is taken. The upper portion of the pericardium is opened in the mid- line to expose the right atrial appendage. The thymic remnant is removed and the innominate vein is com- pletely mobilized. Once feasibility of bypass has been established by assessment of innominate or left internal jugular vein patency, the greater saphenous vein may be exposed by incision of the skin of the thigh over the vein from the groin to the knee. The diameter of the innominate or jugular vein and the length to the right atrial appendage are measured. The diameter of the innominate vein is divided by the average diameter of the saphenous vein. This ratio multiplied by the length from innominate vein to right atrium determines the length of saphenous vein required to construct a com- posite spiral graft of sufficient length and of the same diameter as the innominate vein. For example, if the diameter of the innominate vein is 12 mm and the aver-
age diameter of the saphenous vein is 4 mm, three times the length of saphenous vein will be required to bridge the distance between the innominate vein and right atrial appendage. In practice, excision of saphe- nous vein from groin to knee is usually sufficient.
The side branches of the saphenous vein are ligated and divided. The vein is excised from the leg and gently distended with heparinized electrolyte solution. Any unligated branches are controlled. The vein is opened longitudinally through its entire length. An Ar- gyle thoracostomy catheter of the same diameter of the innominate vein is selected to form a stent over which the composite spiral graft will be constructed. The sa- phenous vein is wrapped around the stent in spiral fash- ion, the endothelial surface placed against the stent. The graft edges are secured at the first complete wrap by suture to allow tension to be maintained on the sa- phenous vein for maximum length as it is spiralled around the catheter. The edges of the graft are secured by suture at the last complete wrap to maintain the configuration. The edges of the saphenous vein are ap- proximated by continuous stitch with 7-0 polypropyl- ene suture. Optical magnification (2.5 power) is used to assure accuracy of the anastomosis and approximation of the endothelial surface. About a 30 minute period is required to prepare the graft.
Heparin, 100 to 300 units/kg, is administered intra- venously to the patient. The innominate vein is ligated
Volume 83 Number 3 March, 1982
Bypass of superior vena cava 3 2 9
as close to the superior vena cava as possible. A soft Fogarty vascular clamp is applied at the jugular- subclavian confluence, and the innominate vein divided so that as much length as possible is preserved. The intima of the innominate vein is inspected to assure that it is normal. Thrombus may be removed which is not adherent, provided the intima of the vein remains nor- mal. Organized thrombus which has become adherent and altered the intimal surface should be removed by completely excising the vein back to normal tissue beyond the thrombosed area. The end of the composite spiral vein graft is trimmed to provide a uniform cir- cumference. The graft is pushed slightly off the end of the stent. An end-to-end anastomosis of the graft to the innominate vein is constructed with continuous stitches of 7-0 polypropylene suture. When the anastomosis is complete, the stent is removed and the graft placed in the mediastinum anterior to the aorta. The entire right atrial appendage is excluded by vascular clamp placed on the right atrium below the base of the appendage. The tip of the appendage is excised and all trabeculae within the appendage are removed to assure an unre- stricted passageway into the atrium. An end-to-end anastomosis of the vein graft to the right atrial append- age is made with 5-0 polypropylene suture (Fig. 2). Prior planning of the orientation of the graft will allow utilization of the naturally occurring bevel of the graft for correct approximation to the atrial appendage. The vascular clamps are removed, protamine administered, and the graft packed for a few minutes to achieve hemostasis. Correct measurement of graft length is es- sential; there is no advantage to excessive length, as hemostasis will not be satisfactory and any angles in the graft will likely be detrimental for patency. The pericardium is left open; wound closure is routine.
Postoperatively, the condition of the patient may temporarily appear worse with more facial and periorbi- tal edema owing to the supine body position with the neck extended during the operation. A 30% to 45% head-up position in bed is optimal. The endotracheal tube should be removed cautiously in case there may be some laryngeal edema. The upper compartment venous system will rapidly decompress so that facial edema will largely disappear within 24 to 48 hours.
Results
All 10 patients having composite spiral vein graft to bypass the superior vena cava have survived the opera- tion and the postoperative period and have been dis- charged from the hospital. Preoperative venography was the most useful diagnostic examination and showed complete occlusion of the superior vena cava in
Fig. 2. Composite spiral saphenous vein bypass graft (arrow) viewed through the midsternal incision. The proximal anas- tomosis to the innominate vein is beneath the sternum on the left. The graft courses across the mediastinum anterior to the aorta (Ao) to join the right atrial appendage (RA).
all cases. The obstruction involved the azygos vein and extended cephalad in the vena cava to involve the innominate-cava junction in all cases, producing sig- nificant distention of the veins in the neck and arms. Patency of the innominate vein or the subclavian-left internal jugular confluence was documented in eight patients; in the other two patients, thrombosis had propagated beyond the thoracic inlet to involve the subclavian-axillary venous system or internal jugular vein on the left side (Fig. 3). In one patient, it was not possible to document left internal jugular vein patency by three attempts at venography. In this case, cervical ultrasound examination demonstrated a patent left in- ternal jugular vein (Fig. 4), which proved adequate for anastomosis to the bypass graft. One patient previously had had a bypass of the right axillary vein to azygos vein with homograft aorta, which had thrombosed. Biopsy of the obstructing process in the right side of the mediastinum provided tissue diagnosis in all cases. In
3 3 0 Doty The Journal of
Thoracic and Cardiovascular Surgery
Fig. 3. Contrast venogram shows that thrombosis of the superior vena cava has propagated into all intrathoracic tributaries. No portion of the innominate vein remains available and any bypass anastomosis must be in the neck above the thoracic inlet.
Fig. 4. Ultrasound image of the long axis of the neck demonstrates patent left internal jugular vein (arrow).
four patients, superior vena cava obstruction was due to a benign process (Table I) and in six patients there was a mediastinal malignancy (carcinoma) (Table II).
The operation was as described in all except three patients. One patient required thrombectomy of the left internal jugular and subclavian veins prior to bypass graft. In this case the thrombus was recent and only moderately adherent to the intima of the vein, so that the thrombus could be removed. Another patient had only the internal jugular vein patent; the sternotomy had to be extended so that an anastomosis could be
performed in the neck above the thoracic inlet. A third patient had involvement of the right atrial appendage with tumor. It was possible, however, to achieve anas- tomosis to the side of the right atrium just above the inferior vena cava. Blood loss was not excessive in any patient, but autotransfusion techniques seemed to be a useful adjunct.
All patients were relieved of symptoms and signs of superior vena cava syndrome within 48 hours after op- eration. In no case did these symptoms or signs return during the follow-up period. Each patient retained
Volume 83 Number 3 March, 1982
Fig. 5. Infrared photograph before operation shows marked subcutaneous venous pattern as well as facial and periorbital edema.
some distention of the external jugular veins, suggest- ing head and neck venous pressure was slightly above normal even though the patients were asymptomatic. Swelling of the arms resolved promptly in the postop- erative period even on the right side, where no direct decompressive procedure was done. Infrared photo- graphs taken of one patient to bring out the superficial vein pattern before and after bypass documented relief of venous distention as well as resolution of facial and arm swelling (Figs. 5 and 6). Superficial veins were prominent only over the right shoulder after operation. Contrast or radionuclide venography documented graft patency during the first week after operation in all cases (Figs. 7 and 8). Late patency at 6 months was docu- mented by contrast venography in the first three cases. Late venograms were not done in other cases, as the symptom-free patients reported accurate clinical follow-up and noninvasive Doppler ultrasound demon- strated differential flow velocity in the internal jugular veins suggesting graft patency. Fig. 9 shows typical
Bypass of superior vena cava 3 3 1
Fig. 6. Infrared photograph after operation shows resolution of venous pattern over left arm, shoulder, and thorax. Venous pattern on the right remains, though less pronounced. Facial and periorbital edema has resolved.
directional Doppler ultrasound examination demon- strating approximately two times the flow velocity in the left internal jugular vein compared to the right side.
Bypass of the superior vena cava was all the therapy necessary for the four patients with obstruction of the superior vena cava due to benign disease. All four have remained completely asymptomatic for periods up to 6 years, results which imply long-term graft patency. All have returned to gainful employment and have good exercise capacity. All can bend or stoop over without symptoms.
All patients with obstruction of the superior vena cava resulting from a malignant process required other therapy aimed at palliation of the primary disease pro- cess. Five of the six received supervoltage radiation to the mediastinum in doses ranging from 3,000 to 6,000 rads. Three of them received chemotherapy; one re- ceived chemotherapy as primary treatment of a small cell carcinoma and the other two were given chemo- therapy later, in an attempt to palliate extrathoracic
3 3 2 Doty The Journal of
Thoracic and Cardiovascular Surgery
Fig. 7. Contrast venography after operation shows patent composite spiral saphenous vein bypass graft between in- nominate vein and right atrium and satisfactory resolution of venous distention. Collateral venous channels remain on the right.
metastasis. Graft patency has been uniform despite these other modes of therapy. The patients tolerated palliative treatments very well in the absence of the distress of superior vena cava syndrome. Satisfactory palliation of 12 months or greater was achieved in four of the six patients. The four patients surviving a year or more were quite comfortable until the last few months. Three of the four returned to their usual employment for several months after palliative therapy was com- pleted. One of them worked for over 15 months and survived for 21 months with a patent graft documented by computerized axial tomography at 18 months (Fig. 10). There were no signs of superior vena cava ob- struction, but the patient eventually died of extensive cerebral, mediastinal, retroperitoneal, and hepatic me- tastases. Two patients died early after operation. One died about 3 weeks after operation at another hospital because of apparent pulmonary embolus and iliofemoral venous thrombosis. This patient was very debilitated at the time of operation, having extensive mediastinal dis- ease and marked aldosterone endocrine effects from the small cell tumor. Another patient died at 5 months of extensive metastasis from anaplastic carcinoma. The mean survival time was 10.7 months. The patients died either at home or in other hospitals and autopsy was done in only one of them (Case 6, Table II). The com-
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Fig. 8. Radionuclide venogram after operation demonstrates patent bypass graft filling right heart from left arm venous injection.
posite spiral saphenous vein graft was shown to be patent 13 months after operation and after the patient received 5,000 rads to the mediastinum. The graft ap- peared to have smooth, glistening endothelium (Fig. 11) and histologic sections revealed normal morphology of the saphenous vein (Fig. 12).
Discussion
Lokich and Goodman3 reported that the major pit- falls in management of superior vena cava obstruction relate to attempts to establish the site of obstruction and to obtain specific tissue diagnosis. In their experience, venography, venous pressure manometry, bronchos- copy , and cervicomediastinal explorations may lead to life-threatening complications such as respiratory ob- struction, aspiration, and hemorrhage. They recom- mended immediate therapeutic intervention to relieve caval obstruction symptoms and later tissue biopsy, since the disease process is malignant in over 90% of cases. Shimm, Logue, and Rigsby,4 to the contrary, found that invasive diagnostic procedures can be car- ried out effectively and safely. They showed that seven of 18 patients presenting with superior vena cava syn- drome as the initial manifestation of disease had small cell carcinoma, which currently appears to be best treated by combination chemotherapy techniques. It should be noted, however, that despite complete work-up, which included exploration of the mediasti- num or thorax in some cases, two of the 18 remained without histologic diagnosis. Recent reviews of su-
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