surgery of superior vena cava

SURGERY OF SURGERY OF SUPERIOR VENA CAVASUPERIOR VENA CAVA

SURGERY OF SURGERY OF SUPERIOR VENA CAVASUPERIOR VENA CAVA

ProfessorProfessorAbdulsalam Y TahaAbdulsalam Y Taha

School of Medicine/ University of Sulaimani/ Iraq

https://sulaimaniu.academia.edu/AbdulsalamTaha

04/14/23 2Prof. Abdulsalam Y Taha

ANATOMY• The right and left innominate veins, which receive

venous blood mainly from the upper thorax, arms, neck and head, are the major vessels returning blood to the SVC.

• The SVC begins at the level of the first right costal cartilage and terminates in the right atrium at the level of the third intercostal space, and is thus located in the superior part of the posterior mediastinum, to the right of the aorta, and anterior to the trachea and right main bronchus.

• The SVC is about 2 cm in diameter and 6–8 cm in length; the last 2 cm are within the pericardial reflection around the right atrium. The extra pericardial part of the SVC is surrounded by numerous lymph nodes.


AZYGOS AND HEMIAZYGOS VEINS

• The azygos is the thoracic continuation of the right ascending lumbar vein; it collects blood from the right posterior intercostal veins and drains into the posterior SVC, just above the pericardial reflection.

• The hemiazygos vein is the continuation of the left ascending lumbar vein; it intercepts the lower left posterior intercostal veins, ascending on the left side of the thoracic spine as far as the eighth thoracic vertebral body, where it crosses over the vertebral column to fuse with the azygos vein.


HISTORY• In 1757 William Hunter described a case of SVC

syndrome caused by a syphilitic aneurysm of the ascending aorta [1].

• In 1837 William Stokes reported the first case of SVC syndrome caused by a malignancy [2].

• In 1949 McIntire and Sykes reported the first series of 502 cases with SVC syndrome mainly caused by benign diseases such as syphilitic aortic aneurysm and chronic fibrous mediastinitis from tuberculosis, only a third of the cases were due to primary thoracic cancers [3].

• Prior to 1949, SVC syndrome had a mainly infectious etiology, now thoracic malignancies are the primary cause.


HISTORY• As regards surgery for SVC syndrome, in 1934

Carlson working on dogs found that SVC ligation below the azygos resulted in the death of all animals, while SVC ligation above the azygos allowed survival, demonstrating that the azygos system is an important collateral pathway [4].

• The first successful bypass operations for SVC obstruction in humans were performed with autologous femoral vein grafts by Klassen in 1951 [5] and Bricker and McAfee in 1952 [6].


HISTORY• In 1961 Benvenuto and colleagues

constructed large caliber bypass conduits from several segments of saphenous vein; these were incised longitudinally, flattened, placed over a stent in a paneled or tiled manner and sewn together to create the conduit [7].


HISTORY• In 1961 Schramel and Olinde described the subcutaneous

tunneling of a long saphenous vein bypass conduit to the jugular vein [8].

• This technique was later adopted by Taylor and associates (1974) [9] and Vincze et al. (1982) [10] in seven patients with SVC obstruction due to lung cancer.

• In 1976 Doty and Baker performed the first successful venous bypass with a spiral saphenous vein graft [11]. This procedure had been developed two years previously by Chiu and associates who performed it in a patient with SVC obstruction secondary to granulomatous mediastinitis [12].

• In 1986 Mitchell and colleagues described two SVC bypasses using intact saphenous vein in patients with mediastinal fibrosis [13].


HISTORY• In 1987 Dartevelle et al. described

13 patients with mediastinal or lung malignancies and SVC involvement: they were treated by SVC resection and reconstruction with polytetrafluoroethylene grafts [14].


Surgery of SVC

• Resection and reconstruction of the SVC is still considered a surgical challenge.

• However, with the appropriate indications and surgical technique a clear benefit has been documented in a selected group of patients.

• The anatomy of the SVC and left innominate vein put this venous system in a critical area vulnerable to tumours arising both in the lung and anterior mediastinum.


INDICATIONS• Malignant invasion is the most frequent indication for

SVC resection and reconstruction.• Lung cancer can involve the vessel with direct

invasion by primary tumours arising in the RUL or by nodal metastases ( stations R2, R4 and 3).

• Anterior mediastinal tumours ( thymoma, thymic carcinoma, germ-celltumours,etc) may involve directly both the SVC and the left innominate vein.

• Primary tumours of the SVC represent a rare indication for surgery.

• Infrequent indications: saccular aneurysms, primary malformations and traumatic lesions( iatrogenic, blunt, or penetrating injuries).


CONTRAINDICATIONS

• The presence of SVC syndrome related to unresectable tumours.

• A completely obstructed SVC with a rich collateral vein circulation.

• Abnormal walls of the proximal veins i.e., tumour involvement at the margins.


PREOPERATIVE WORK-UP• Total body CT scan for patients with lung cancer or

tumours of the mediastinum.• Superior vena cavography should be performed when

SVC invasion is suspected.• MRI: site and extent of infiltration, thrombosis and

anatomical variations of the SVC system.• Echocardiography: to rule out right atrial thrombosis.• Brain CT scan for staging lung cancer and also to rule out

any brain disease that may be exacerbated by CNS oedema during SVC clamping.

• PFTs and ABG analysis; since some patients with RUL lung cancer invading the SVC are candidates for standard pneumonectomy or pneumonectomy with carinal resection.


OPERATIVE STEPS

• Surgical Approach: Right thoracotomy in 4th or 5th

intercostal space is the standard approach for upper lobe tumours invading the SVC. But control of left innominate vein is difficult.

Complete median sternotomy is recommended for tumours of anterior mediastinum.


INTRAOPERATIVE MANAGEMENT

• Resection and reconstruction ot the SVC is considered a major technical challenge due to the potential detrimental effects of clamping a patent vessel.

• Partial caval clamping or clamping a chronically obstructed SVC is generally well tolerated; on the other hand, occlusion of a patent SVC may produce intracranial bleeding, brain oedema and damage, and a potentially lethal reduction of cardiac output.

• These complications can be avoided by careful patient selection and intraoperative monitoring and management.


INTRAOPERATIVE MANAGEMENT

• Double lumen ETT• Radial art line• Central venous line in internal JV• 2 additional venous lines in lower limbs

for volume expansion during caval clamping.

• Foley catheter.• ECG monitoring.• TEE and NG tube are optional.


INTRAOPERATIVE MANAGEMENT• Fluid imlementation and pharmological agents:

macromolecules, blood and plasma should be used.

• Vasoconstrictive agents are used to increase the mean art pressure.

• Diuretics are given at the end of op to reduce oedema in cephalic region.

• Anticoagulant therapy: iv heparin 0.5 mg/kg before clamping and continued during the immediate postop period INR= 2 to 2.5; switched to warfarin at time of discharge.


SURGICAL STRATEGY AND SHUNTING TECHNIQUES

• For lung cancer, the vascular step should be always performed before airway reconstruction.

• Every effort should be attempted to reduce clamping time as much as possible. Up to 45 to 60 minutes of complete clamping is usually tolerated with the appropriate pharmological support.

• Intravascular or extravascular shunts may be used to reduce the effects of vascular clamping during resection and reconstruction of the SVC.


SURGICAL TECHNIQUE

• Tangential resection and venous plasty: in cases with less than 30% of the SVC circumference is involved.

• Resection is needed for larger defects.• Replacement is achieved by a patch of

autologous or bovine pericardium. Autologous pericardium may be fixed in 2 drops of 20% glutalaldehyde in 50 cc of saline for one minute to let it stiffen and facilitate suturing.


SURGICAL TECHNIQUE

• SVC replacement is the most frequent type of reconstruction. It is usually performed using a straight non- ringed PTFE graft(18-20mm).

• An autologous or bovine pericardial tube could also be used.

• Sometimes it may be indicated to replace only one innominate vein according to local invasion. A ringed PTFE should be used.

• Simultaneous revascularization of both innominate veins is rarely required.

• Palliative bypass is extremely rare due to low venous blood flow obtained from the axillary or jugular veins.


COMPLICATIONS

•Anastomotic stenosis.•Graft thrombosis.•Graft infection.


RESULTS

• Operative mortality should be between 5% and 10%.

• The survival rate after radical resection of mediastinal tumours invading the SVC is excellent: 60% at 5 years according to Dartevelle and collaegues.

• Patients with lung cancer show a less favorable prognosis: about 30% at 5 years.

• There are no long-term survivors among patients with N2 disease.


Complete SVC substitution. Approach: lateral thoracotomy; lung resection: superior right double sleeve lobectomy; ringed PTFE (n. 10) prosthesis for pulmonary artery; and ringed PTFE (size 12) prosthesis for SVC–SVC anastomosis.


Complete SVC substitution for NSCLC. Approach: lateral thoracotomy; lung resection: tracheal sleeve. SVC reconstructed with heterologous

pericardial graft, SVC-SVC anastomosis.


Germ cell cancer of mediastinum. Approach: clamshell and median

sternotomy; partial resection of SVC and left innominate vein; no reconstruction.


Left innominate vein substitution and partial SVC resection for mediastinal tumour. Approach:

sternotomy; lung resection: left superior lobectomy with complete antero–superior mediastinectomy and pericardiectomy (B). Left innominate vein

reconstructed with autologous pericardium (A).


Complete SVC substitution. Approach: lateral thoracotomy; lung resection:

tracheal sleeve pneumonectomy; ringed PTFE (size 14) prosthesis serves to achieve

SVC–SVC anastomosis.


Complete SVC substitution. Both innominate veins resected for mediastinal tumour; approach:

sternotomy; no lung resection; ringed PTFE (size 12) prosthesis for anastomosis between left

innominate vein and SVC.


(A–B). Complete SVC substitution. Approach: lateral thoracotomy; lung

resection: tracheal sleeve lobectomy with neocarina (B) SVC–SVC anastomosis with

PTFE prosthesis (size 14).


Resection performed after partial SVC clamping. SVC reconstruction by a running

polypropylene 5/0 suture.


After partial SVC resection (A) a patch of autologous pericardium has been used to repair the defect (B). In this case the SVC

clamping was complete.


(A–B) Partial resection of SVC by stapler after complete control of the vessel, but

without clamping, for infiltration of azygos-caval confluence; (C) shows reduction in

the final caliber of SVC.


Complete SVC substitution with right and left innominate veins resection for NSCLC. Approach:

transmanubrial and lateral thoracotomy. Lung resection: right superior lobectomy. SVC

reconstructed with PTFE (size 12) prosthesis and anastomosis between right innominate vein and

SVC.


Complete SVC substitution for NSCLC. Approach: lateral thoracotomy; lung

resection: tracheal sleeve. SVC reconstructed with heterologous pericardial prosthesis, SVC–SVC anastomosis. Note the

reconstruction of the pericardial defect with the same pericardial patch used for

SVC prosthesis. 04/14/23 34Prof. Abdulsalam Y Taha

TRAUMA TO SUPERIOR VENA CAVA

•Iatrogenic•Penetrating•Blunt


SVC TRAUMA• Superior vena cava is vulnerable to

injuries of different kinds. Most of the reported injuries are iatrogenic; resulting from placement of central venous catheters, insertion of pacemakers, stenting of SVC in SVC obstruction syndrome or placement of a filter in the SVC to prevent showering of emboli.

• Blunt and penetrating trauma to SVC is rare and highly fatal


CASE REPORT• Herein, we report a case of isolated SVC

injury by big shrapnel who unfortunately expired in the operating theatre because of uncontrolled hemorrhage. The case is presented with review of up to date medical literature. The aim is to recognize methods of early detection and measures of successful surgical repair.


Case History• A 30 year old man was transferred from Kirkuk to

Sulaimania after a big terrorist explosion at June 2007. He had an injury by shrapnel to the right neck root. He arrived few hours after the explosion with right-sided tube thoracostomy draining about 1400 cc blood. On arrival, he was pale and mildly dyspnoic. His blood pressure was low and pulse was rapid. Air entry was diminished on right chest. He had a wound 4 cm in size overlying the medial half of right clavicle. There was on other injuries. Chest radiograph revealed a moderate-sized clotted haemothorax and a big shell in upper chest. Lateral views were obtained twice but were of poor quality and thus did not reveal the shell.


• The patient was resuscitated and prepared for right thoracotomy to drain the clotted haemothorax and stop the source of bleeding and to deal with any intra-thoracic injuries.

• The patient was taken to operating theatre. The operating room was very crowded that night due to other emergency operations being performed simultaneously on other injured patients.

• The patient looked relatively stable. General anesthesia was given via a single lumen endotracheal tube. Right thoracotomy was chosen as that was the side of bleeding. The chest was entered through 5th intercostals space. Large clots were found (about 1000 cc) in the pleural space posteriorly and removed completely. The lung was healthy. There was a big and bulky shell (3 cm in length) in the SVC just above the junction of the azygos vein with the SVC with bleeding around it.

• Once the shell is dislodged, severe bleeding started. The bleeding was initially controlled by manual compression while we prepared ourselves to repair the injury. This has failed; once the hand is released, the field is flooded with blood despite suction. A Foleys catheter is used to tampon the bleeding temporarily. The balloon could not be advanced enough distally because the tear was just at the confluence of innominate veins with the SVC. Repair was not possible with this big balloon in the tear. Surgical dissection was done and the SVC distal to the tear was isolated and clamped but it was not possible to do so proximally. Attempts to control the injury with a side clamp also failed. Meanwhile, the haemodynamic state of the patient was deteriorating. Ultimately, the patient expired.


Alan Walsh and Howard S. Snyder. Azygos vein laceration following a vertical deceleration injury. The Journal of

Emergency Medicine. Vol 10, pp 35-37, 1992.

• Case Report: A 41 year old man presented with

respiratory distress and hypotension after a 30-foot fall from a tree. Despite fluid resuscitation, the patient expired in the operating room. Autopsy revealed an azygos vein laceration at the junction of the SVC as the cause of death.




• Traumatic injuries to the SVC and azygos vein are virtually secondary to penetrating trauma.

• They are rare following blunt chest trauma, including vertical deceleration injury.

• Vascular injuries should be considered in any patient with a massive haemothorax. Exsanguination may result without aggressive resuscitation and rapid surgical intervention.

• Despite optimal care, thoracic venous injuries have a high mortality.


Ochsner JL, Crawford ES and Debakey ME. Injuries to the vena cava caused by

external trauma. Surgery, 1961,49: 397-405

• Ochsner reported 2 patients with SVC rupture from crushing injuries.

• Both patients died prior to arrival in the emergency department.


Lukas GM, Hutton JE, Lim RC and Matthewson C. Injuries sustained from high velocity impact with water. J Trauma 1981;

21: 612-28

• Blunt SVC rupture was found in 2 of 161 patients who jumped from the Golden Gate Bridge.




•Unfortunately, there are no pathognomonic signs of azygos or SVC injuries.




• Pulmonary, hilar and intercostal vessel injuries also present with haemothorax.

• Subclavian, brachiocephalic and aortic injuries must also be considered.




• Thoracic venous injuries usually present with signs of shock.

• The blood pressure in these vessels is normally below systemic pressures, but the flow is high.

• Bleeding is usually massive.




• Depending upon the exact site of injury, bleeding into the pleural cavity or mediastinum results.

• An injury to the SVC at its entrance into the pericardium can produce pericardial tamponade.




• Aggressive fluid resuscitation and blood transfusion are important to prevent haemodynamic collapse prior to transporting these patients to operating room where better lighting and equipment are available.




•Autotransfusion is helpful when blood loss is massive as it uses blood drained from the pleural cavity to restore circulating blood volume.




• SVC injuries, resulting from blunt or penetrating trauma will result in death before admission to the hospital in 45% of cases.

• One third to one half of the remaining patients will die despite aggressive resuscitation and early surgical intervention.

• The high mortality is due to difficulty in diagnosis and technical problems with repair.


G.M. Tiao, P.M. Griffith, J.R. Szmuszkovicz, and Hossein Mahour. Cardiac and Great Vessel Injuries

in Children After Blunt Trauma: An Institutional Review. Journal of Pediatric Surgery, Vol 35, No 11,

2000: pp 1656-1660

• Case• A 9-year- old boy, was struck by an automobile that

was traveling at moderate speed. He sustained bilateral pulmonary contusions and a right pneumothorax requiring tube thoracostomy. The initial CXR showed a widened mediastinum, and a chest CT was suggestive of presence of blood around the aorta. Angiography results showed a contained tear in the SVC. The patient was treated nonoperatively, and he was discharged home 10 days after admission. The patient has remained well for 6 years.


Robert J.Stallone, Roger R. Ecker, Paul C. Samson. Management of major Acute Thoracic vascular

Injuries. The American Journal of Surgery. Vol 126, August 1974


Robert J.Stallone, Roger R. Ecker, Paul C. Samson. Management of major Acute

Thoracic vascular Injuries. The American Journal of Surgery. Vol 126, August 1974


R. Nair et al. management of penetrating Cervicomedistinal Venous trauma. Eur J

Endovasc Surg 19, 65-69 (2000)




• A 25-year-old patient had an unsuccessful resuscitative thoracotomy at which a 4 cm wound in the SVC was clamped.

• The choice of incision was based on established practice; median sternotomy was done for one patient with SVC injury.



Endovasc Surg 19, 65-69 (2000)• In this study, 8 patients(26.7%) died. All of them

were shocked on admission.• Four of the 9 patients who were admitted in

profound shock died on the operating table from exsanguinating haemorrhage.

• In this study, there were 3 patients with SVC injuries.

• Two patients with stab wounds of SVC died on the operating table ( 66% mortality)

• One was ligated and one clamped only, with the patient suffering cardiac arrest immediately thereafter.




• One patient with SVC injury has survived.

• He had an extensive laceration of SVC at the confluence of the brachiocephalic veins.

• He was subjected to venorrhaphy, narrowing the lumen of the SVC to 25% of its normal calibre.

• Postoperatively, he developed massive oedema of the arms, head and neck.




• Little has been written about cervicomediastinal venous injury.

• Repair should be undertaken in stable patients.

• In haemodynamic unstable patient or when complex repair is needed, ligation is the preferred option.


P.N. Symbas,E. Kaourias, D.H. Tyras, C. R. Hatcher, J.R. Penetrating

Wounds of Great Vessels. Ann. Surg, May 1974

• 36 patients with penetrating wounds of the great vessels treated at Grady Memorial Hospital during a 7-year period (1965-1972) were reviewed.

• One patient had 2 stab wounds of the SVC.

• Tangential partial occlusion of the SVC was used.




• The true incidence of penetrating wounds of the great vessels is not known since many of these patients succumb shortly after injury and autopsy examination is not done in all patients dying after trauma.




•Most of these patients underwent auto-transfusion which greatly contributed to their successful outcome.




• In order to overcome the difficulty in promptly procuring sufficient quantities of blood in cases of massive haemorrahage, auto-transfusion is used.

• This procedure has been proved to be safe and frequently life-saving for patients with intra-thoracic bleeding.




•For cases with cervical-thoracic injury requiring emergency exploration for intra-thoracic bleeding there is no incision which will satisfy all needs.




• The trap door incision ( antero-lateral thoracotomy, upper midsternotomy and lower neck incision) has the advantage that it can be extended to gain access to almost all great vessel wounds but is associated with greater morbidity to the patient and is more time-consuming for the surgeon.




• Wide prepping and draping of the thorax and neck so that the thoracotomy incision can be extended if needed, good exposure, adequate assistance, effective suction, sufficient blood for transfusion( or the use ofintra-operative auto transfusion) are essential for the success in the repair of great vessel injury.


CONCLUSIONS• SVC injuries are both iatrogenic and traumatic.• Iatrogenic injuries are common and can be diagnosed

preoperatively and the proper surgical approach chosen accordingly.

• Penetrating SVC injuries are rare. They can be caused by stab or missile wounds.

• No case of SVC shrapnel injury is found in English medical literature search and no case of retained shrapnel in the SVC is reported before.

• Penetrating SVC injuries are highly lethal.• No pathognomonic signs of SVC injury exist to allow a

preoperative diagnosis. However, great vessel injury could be suspected with massive haemothorax, persistent shock and a wound in neck root.


CONCLUSIONS• No incision is ideal and satisfactory to deal

with cervicomediastinal venous injuries in general or SVC injury in particular.

• The high fatality of SVC injuries is due to difficult diagnosis, difficult repair, severe bleeding and consequences of SVC clamping in the acute setting.

• Successful repair may be achieved with good operating conditions, proper lighting, effective suction, adequate assistance, autotransfusion and good anaesthetic management.


REFERENCES

• 1.Hunter W. The history of an aneurysm of the aorta with some remarks on aneurysms in general. Med Observ Inq 1757;1:323.

• 2.Stokes W. A treatise on the diagnosis and treatment of diseases of the chest. I Diseases of the lung and windpipe. Dublin: Hodges Smith, 1837:370.

• 3.McIntire FT, Sykes EM Jr. Obstruction of the superior vena cava: a review of the literature and report of two personal cases. Ann Intern Med 1949;30:925–960.

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• 5.Klassen KP, Andrews NC, Curtis GM. Diagnosis and treatment of superior-vena-cava obstruction. AMA Arch Surg 1951;63:311–325.[Medline]

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• 7. Benvenuto R, Rodman FS, Gilmour J, Phillips AF, Callaghan JC. Composite venous graft for replacement of the superior vena cava. Arch Surg 1962;84:570–573.[Medline]

• 8. Schramel R, Olinde HDH. A new method of bypassing the obstructed vena cava. J Thorac Cardiovasc Surg 1961;41:375.

• 9. Taylor GA, Miller HA, Standen JR, Harrison AW. Bypassing the obstructed superior vena cava with a subcutaneous long saphenous vein graft. J Thorac Cardiovasc Surg 1974;68:237–240.[Medline]

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• 12. Chiu CJ, Terzis J, MacRae ML. Replacement of superior vena cava with the spiral composite vein graft. A versatile technique. Ann Thorac Surg 1974;17:555–560


• 13. IM, Saunders NR, Maher O, Lennox SC, Walker DR. Surgical treatment of idiopathic mediastinal fibrosis: report of five cases. Thorax 1986;41:210–214.

• 14. Dartevelle P, Chapelier A, Navajas M, Levasseur P, Rojas A, Khalife J, Lafontaine E, Merlier M. Replacement of the superior vena cava with polytetrafluoroethylene grafts combined with resection of mediastinal-pulmonary malignant tumors. Report of thirteen cases. J Thorac Cardiovasc Surg 1987;94:361–366.

• 15. Spaggiari L, Thomas P, Magdeleinat P, Kondo H, Rollet G, Regnard JF, Tsuchiya R, Pastorino U. Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study. Eur J Cardiothorac Surg 2002;21:1080–1086.


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