Reconstruction of the superior vena cava in patients with mediastinal malignancies.

We performed reconstruction of the superior vena cava (SVC) and left brachiocephalic vein following extensive resection of malignant thymic tumours in eight patients, five of whom had invasive thymoma. The other patients each had a thymic Hodgkin's lymphoma, thymic carcinoma and thymic germ cell tumour. Teflon grafts were used in the first two cases and expanded polytetrafluoroethylene (EPTFE) grafts in the subsequent six cases. Occlusion occurred only in one SVC graft and two left brachiocephalic vein grafts. The mean survival after this operation was 35 months, with the longest survivor showing no occlusive symptoms for 8 years. This operation not only alleviates the symptoms of the SVC syndrome but may also improve the prognosis of such patients.     

Two cases of atrial septal defect with absence of right superior vena cava and persistent left superior vena cava]

Two women (16-year-old, 54-year-old) of atrial septal defect with absence of right superior vena cava and persistent left superior vena cava were successfully operated on. Electrocardiographic findings show coronary sinus rhythm and atrial fibrillation. When we closed atrial septal defect cannulated to persistent left superior vena cava via the coronary sinus directly, sick sinus syndrome was not appeared postoperatively.     

Combined resection of superior vena cava for lung carcinoma: prognostic significance of patterns of superior vena cava invasion

Background

Combined resection of the superior vena cava (SVC) for lung carcinoma remains challenging in terms of technical aspect and prognosis. We attempted to clarify the surgical outcome of combined resection and reconstruction of the SVC for lung carcinoma.

Methods

Between March 1980 and May 2001, among 3,499 lung resections, 40 (1.1%) patients underwent combined resection of the SVC. Thirty-four were men and 6 were women. Ages ranged from 37 to 77 years, with median of 64 years. Lobectomy and pneumonectomy was performed in 19 and 21 patients, respectively. The SVC system was totally resected and reconstructed with grafts in 11 patients, and partially resected in 29 patients. For the latter patients, autologous pericardial patches were used in 8 patients, and a running direct suture was performed in 21 patients. The survival curves were constructed by the method of Kaplan-Meier, and the curves were compared using the log-rank test.

Results

Thirty-day mortality was 10%. The 5-year survival rate was 24%, with the median follow-up period for living patients 67 months (actual 5-year survivors were 7). The prognoses were compared between patients with SVC invasion by metastatic nodes (n = 15) and those with SVC invasion by a direct tumor extension (n = 25), and the survival difference was statistically significant (5-year survival rate, 6.6% versus 36%; p = 0.05).

Conclusions

The pattern of SVC invasion was considered to be a significant prognostic factor, and this factor should be taken into consideration for evaluating the outcome of clinical trials for T4 lung cancer.     

Absent right superior vena cava with left superior vena cava draining into unroofed coronary sinus with common atrium in a child with an atrioventricular septal defect

The association of absent right superior vena cava and persistent left superior vena cava draining into unroofed coronary sinus with common atrium and the atrioventricular septal defect is an extremely rare form of the congenital cardiac disorder with only one case reported so far, hence, can be missed preoperatively if not carefully looked for. Failure to detect absent right superior vena cava beforehand may otherwise pose difficulties in carrying out invasive surgical or medical interventions.     

Surgical management of persistent left superior vena cava associated with an absent right superior vena cava

A case of persistent left with absent right superior vena cava accompanied with atrial septal defect in a six-year-old girl is presented. This rare venous malformation was diagnosed incidentally during surgery when the pericardium was incised. An L-shape cannula was directly inserted into the left superior vena cava for cardiopulmonary bypass. The atrial septal defect was closed with a fresh autologous pericardial patch. The surgical management of this rare anomaly is the subject of this review.     

Surgical strategy for invasive pulmonary and mediastinal tumors requiring superior vena cava reconstruction

During the past 16 years, 22 patients were operated on concomitantly with superior vena cava (SVC) reconstruction in our university hospital. Among them, 19 patients had anterior mediastinal tumor and 3 advanced lung cancer. They were 13 males and 9 females, ranging in age from 16 to 70 (mean, 51.4) years. Severe SVC syndrome was found in 10 cases of them. The anterior mediastinal tumors consisted of invasive thymoma in 10 cases, thymic Hodgkin's disease in 2, seminoma in 2, and thymic cancer, thymic carcinoid, thyroid cancer, metastasis of chondrosarcoma and yolk sac tumor in each one. Regarding SVC reconstruction, anatomical bypass was performed in 18 cases, in addition to a radical resection of the tumor. The left innominate vein was reconstructed in 5, the right innominate vein including SVC in 4 and bilateral veins in 9. Extra-anatomical bypass was performed in 4 cases with unresectable tumors because of severe SVC syndrome. Subclavian-femoral vein bypass was performed in one and internal jugular-femoral vein bypass in 3. In anatomical bypass, 7 cases have been alive now though 11 died, and graft patency rate was 82% in the right and 38% in the left. All 4 cases with extraanatomical bypass showed improvement of SVC syndrome, but died one to seven months postoperatively. In conclusions, radical operation with reconstruction of SVC was effective to long-term survival and improvement of SVC syndrome. Extraanatomical bypass improved postoperative quality of life remarkably.     

Assisted thoracoscopic resection of huge mediastinal neurogenic tumor with Horner syndrome and superior vena cava syndrome

A 51-year-old female suffering from right shoulder pain had chest radiography, which showed the huge round shadow (10 x 8.5 x 8.0 cm) on the right upper lung field. Horner syndrome and superior vena cava syndrome were presented. Thoracoscopic appearance showed that the tumor with complete smooth capsulation was neurogenic. After that added ideal thoracotomy (compatible with location and length) was performed, from which tumor was carried out and made a pathologic diagnosis of neurilemoma originated from thoracic sympathetic nerve. Harmonic Scalpel, an ultrasonically activated surgical device was effective in such a case of using near by nerve and small vessels. After operation, superior vena cava syndrome except for Horner syndrome was improved. It is important that we should consider less invasive and safe approach with combination of thoracoscopic and thoracotomic procedures even in case of huge tumor.     

Accessory left superior vena cava

The authors conducted contrast study of the position of the cavacatheter in all patients treated in the period of 12 months in the thoracic surgery department and the anesthesiology-resuscitation department who required long-term intensive therapy. In 61 of these patients the catheter was introduced through the left subclavian vein. An accessory left superior vena cava (ALSVC) which drained through the coronary sinus into the right atrium was found in 3 patients (4.9%). Study of the anatomical features of this venous anomaly led to the conclusion that prolonged infusion therapy through an ALSVC is undesirable.     

Thrombosis of the inferior vena cava by seminoma

We report a case of metastatic seminoma that caused thrombosis and obstruction of the inferior vena cava. The pathogenesis of this rare clinical entity is discussed. The diagnostic studies for detection of vena caval thrombosis and clinical management strategies are reviewed.