Bilateral resection and reconstruction of internal jugular vein for thyroid carcinoma

Two patients with thyroid carcinoma infiltrating bilateral internal jugular veins were treated. In reconstruction of the internal jugular vein by implantation of an autogenous venous segment or Gore-Tex artificial vessel, the repaired area soon became obstructed. The repaired area with the Impra-Flex artificial vessel became obstructed again one month after the implantation. In the reconstruction by ipsilateral end-to-end anastomosis between the internal and external jugular veins, good circulation was apparent even 2 years after the operation. The internal-external jugular vein anastomosis is expected to increase the safety of single-stage bilateral excision of the internal jugular vein, as an adjunct to total thyroidectomy, in the surgical treatment of thyroid carcinoma.     

Thyroid cancer with massive invasion into the neck and mediastinal great veins

Papillary thyroid carcinoma with massive invasion into the great veins of the neck and mediastinum has rarely been reported and is thought to have a poor prognosis. Here we report successful management of a case of papillary thyroid carcinoma with extensive invasion into the left internal jugular vein, left brachiocephalic vein, and superior vena cava, followed by reconstruction of the superior vena cava using an artificial graft. The operation was conducted to prevent sudden death due to complete obstruction of venous flow, improve the patient's quality of life, and prolong survival. The patient has survived for more than two years after surgery, with good general condition.     

Thyroid cancer with massive invasion into the neck and mediastinal great veins

Papillary thyroid carcinoma with massive invasion into the great veins of the neck and mediastinum has rarely been reported and is thought to have a poor prognosis. Here we report successful management of a case of papillary thyroid carcinoma with extensive invasion into the left internal jugular vein, left brachiocephalic vein, and superior vena cava, followed by reconstruction of the superior vena cava using an artificial graft. The operation was conducted to prevent sudden death due to complete obstruction of venous flow, improve the patient's quality of life, and prolong survival. The patient has survived for more than two years after surgery, with good general condition.     

Reconstruction of jugular and portal blood flows using remodeled great saphenous vein grafts

Remodeled great saphenous vein grafts were used to reconstruct both jugular and portal veins. The great saphenous vein was split longitudinally and sutured side-to-side to construct a vessel twice the diameter and one half the length of the original vessel. This graft was used with good results for reconstruction of the jugular veins in a patient after a bilateral neck dissection for tongue cancer and for a portal vein in a patient after resection for cancer in the head of the pancreas.     

Internal jugular vein reconstruction using a superficial femoral vein graft.

Numerous methods of venous reconstruction have been described to help prevent the many complications related to bilateral ligation of the internal jugular veins. The authors report a case in which the superficial femoral vein was used as the donor graft for reconstruction of the internal jugular vein in a 61-year-old man who underwent a tonsillar commando procedure for cancer. The advantages of using this donor vein for reconstruction of the internal jugular vein are summarized.     

Internal jugular vein occlusion in head and neck microsurgical reconstruction

The internal jugular vein has been the preferred recipient vein in head and neck microsurgical reconstruction. However, recent reports have demonstrated internal jugular vein occlusion after functional neck dissection. The purpose of this article is to demonstrate and discuss the possibility of recipient internal jugular vein occlusion after free tissue transfer. Of 58 patients who received an end-to-side venous anastomosis with the internal jugular vein, four cases of recipient internal jugular vein occlusion were detected during the early postoperative period. Although the success rate of end-to-side anastomosis with the internal jugular vein may be high, microsurgeons should be aware of the possibility of internal jugular vein occlusion.     

Superior vena cava syndrome: relief with a modified saphenojugular bypass graft

Superior vena cava (SVC) syndrome is a disabling and potentially life-threatening complication. SVC revascularization can be achieved by means of endovascular or direct surgical reconstructions. In the patient on whom we report, these two options were not possible, and a peripheral venous bypass grafting procedure was done with a technical innovation. Right upper-extremity swelling developed in a 55-year-old woman after radiation therapy for lung carcinoma. A left subclavian vein Port-A-Cath induced extensive thrombosis of the left innominate, axillosubclavian, and jugular veins. She was referred to our institution with very symptomatic SVC syndrome after two failed endovascular interventions. The occlusion of both innominate veins and chronic thrombus extending into the left axillosubclavian and internal jugular veins was confirmed by means of a venogram. A third endovascular attempt failed. The presternal skin had severe radiation-induced damage precluding direct SVC reconstruction. A bypass grafting procedure from the right internal jugular to the femoral vein was performed with spliced bilateral greater saphenous veins tunneled inside an externally supported expanded polytetrafluoroethylene graft. Postoperatively, the patient had no symptoms, and graft patency was confirmed by means of duplex ultrasound scanning. A saphenojugular bypass grafting procedure can offer prompt and durable relief of SVC syndrome when endovascular or direct surgical reconstructions are not possible. This rarely used peripheral venous bypass grafting procedure was modified by tunneling the vein graft inside an externally supported polytetrafluoroethylene graft to prevent kinking or compression.     

Superiority of end-to-side anastomosis with the internal jugular vein: the experience of 80 cases in head and neck microsurgical reconstruction.

The authors report their experience with 80 head and neck reconstructions using free-tissue transfer in which end-to-side anastomosis with the internal jugular vein was carried out. An end-to-side anastomosis with the internal jugular vein has the following advantages. Firstly, the technique overcomes the problems of vessel size discrepancy. It is effectively applied for free jejunal transfer or combined flap transfer based on a single vascular pedicle, of which the size of the proximal end of the drainage vein is very large. Secondly, the internal jugular vein has wide capacity to be the recipient of two or more end-to-side anastomoses. It is effectively used for free radial forearm or rectus abdominis myocutaneous flaps in which two or more drainage veins can be included. Thirdly, the respiratory venous pump effect may act directly on the venous drainage of the transferred flap through the internal jugular vein. In our institution, these advantages have made it the technique of choice in head and neck reconstructive microsurgery.     

The Pruitt-Inahara carotid shunt as an assisting tool to anastomose the arterial free flap pedicle to the internal carotid artery in the vessel-depleted neck

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels which are frequently compromised by prior surgery or radiotherapy to the neck. This article details a new technique of arterial free flap pedicle anastomosis to the internal carotid artery in a vessel-depleted neck. A 63-year-old female was referred because of recurrence of squamous cell carcinoma of the tongue, which involved the left-sided tongue base and pharynx with circumferential involvement of the homolateral external carotid artery. This artery and its branches were excluded as potential recipients. To close the defect after tumor excision, a free vertical rectus abdominis muscle arterial flap pedicle was anastomosed to the homolateral internal carotid artery with the help of a Pruitt-Inahara outlying carotid shunt. The venous anastomosis was performed to the internal jugular vein. The VRAM flap survived without complications. This procedure is to be considered an alternative rescue technique for salvage reconstruction in vessel depleted necks.     

An algorithm for recipient vessel selection in microsurgical head and neck reconstruction

This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.     

New microvenous anastomosis model for microsurgical training: external jugular vein

In microsurgical training, the femoral vein is used frequently for a microvenous anastomosis model. But the femoral vein in the rat does not completely simulate the human vein because of its thin wall, fragility, and tendency to collapse. These anatomic characteristics cause some difficulty in carrying out anastomoses in microsurgery training particularly for beginners. The authors propose the external jugular vein of the rat for microsurgical training in microvenous anastomoses. In 10 Wistar rats, the anatomy of the external jugular vein was studied by dissection and histology. Anatomic dissections demonstrate that the external jugular vein has an average diameter of 1.9 mm (range: 1.6 to 2.1 mm) without tendency to collapse. The vein is easily dissected without any accompanying anatomic structure for an average segment of 45 mm, allowing effortless approximator clamp placement. Comparison of its cross section with that of the femoral vein and other previously described models by light microscopy and scanning electron microscopy reveals a larger diameter and much thicker vessel wall with a prominent tunica media and adventitia. Based on the anatomic findings in 20 rats, the external jugular vein was anastomosed with end-to-end standard microsurgical technique using 8-0 (n = 10) and 10-0 (n = 10) nylon sutures. Results indicate a 100 percent patency rate immediately after the anastomosis for the two subgroups and 100 percent and 90 percent patency rates 1 week after the procedure for the 10-0 and 8-0 nylon suture groups, respectively. This model presents some advantages: the vein is easily dissected with the naked eye without using the operating microscope because it is the largest vein among the superficially located veins in the rat, and has a thick vessel wall without tendency to collapse. The operative area allows for training inbilateral microsurgical anastomoses using a single skin incision and is safe from autocannibalization. The model simulates clinical microvenous anastomosis better because of its similarities to human large diameter flap veins.     

Mathematical simulation of intracranial condition--Part 1. Linear model stimulation]

We developed a linear mathematical model of the intracranial vessels, which reflects changes of the pulse wave (pulse pressure) of intracranial pressure after ligation of the internal jugular vein. The model composed of eight major variables: 1. resistance of arteries, 2. resistance of small arteries and capillary vessels, 3. resistance of veins, 4. resistance of internal jugular and vertebral veins, 5. compliance of arteries, 6. compliance of small arteries and capillary vessels, 7. compliance of veins and 8. intracranial compliance. All variables are presumed to have linear elements and replaced with electrical elements. The model of neck dissection is expressed as the change of resistance of the internal jugular and vertebral veins. Intracranial condition is expressed as the pulse wave (pulse pressure) of intracranial pressure and driving pressure. After unilateral ligation of the internal jugular vein, the pulse wave of intracranial pressure increased 24% and, after bilateral ligation of the internal jugular vein, it increased 55%. After unilateral ligation of the internal jugular vein, the pulse wave of intracranial pressure increased 27%, and, after bilateral ligation, it increased 79%. When intracranial compliance is normal, the respective ratios of pulse wave of intracranial pressure and driving pressure to cross-sectional area decreased, whereas those after increase of intracranial compliance increased.     

Surgical treatment of congenital spindle-shaped aneurysms of the internal jugular vein]

In 6 of 12 investigated patients resection of a congenital aneurysms of the internal jugular vein was accomplished. In 2 of them venous patency was restored by means of a longitudinal-lateral suture after resection of a sac-shaped aneurysm, while in 4--following circular resection of a spindle-shaped aneurysm the vein was reconstructed by an end- to-end anastomosis. Phlebographic studies in 2 patients 10 and 12 months after reconstruction of the internal jugular vein have demonstrated great perspectives of employing such operation in clinical practice.     

Comparison of end-to-end and end-to-side venous anastomosis in free-tissue transfer following resection of head and neck tumors

A comparative study was conducted of the results of venous end-to-end and end-to-side anastomosis in 948 clinical cases of microvascular free-tissue transfers for head and neck reconstruction following tumor resection. End-to-side anastomosis to the internal jugular vein was achieved uneventfully in the present series, while a variety of recipient veins was used for end-to-end anastomosis. The incidence of thrombosis was 1.8% (15/835) in the end-to-end anastomosis group and 2.7% (3/113) in end-to-side venous anastomosis. No statistical difference was observed between the two groups. One may hesitate to perform end-to-side anastomosis because of unfamiliarity, concern over technical difficulty, and unreliability. As a result of our statistical analysis, we are convinced that end-to-side anastomosis directly to the internal jugular vein, whenever available, is the preferred procedure in microvascular free-tissue transfers for reconstruction of the head and neck following tumor resection. © 1996 Wiley-Liss, Inc.     

A case of chronic fibrosing mediastinitis]

This case report describes a 32-year-old male patient with superior vena cava syndrome due to chronic fibrosing mediastinitis involving superior vena cava, bilateral brachiocephalic, subclavian, and internal jugular veins. Although the ringed ePTFE graft was placed between left internal jugular vein and right atrium twice, it occluded each time. Pathological examination of the removed specimen showed invasion of the fibrous tissue into the lumen of the graft at the anastomotic site and severe fibroelastosis in the intima of the jugular vein. The third reconstruction of the venous system with the ringed ePTFE substitute was done in the same manner. Postoperative venography demonstrated the patent graft and the interruption at the midportion of the left internal jugular vein. The patient remains free from the symptoms one year and nine months after the last operation.     

Bypass of superior vena cava. Fifteen years' experience with spiral vein graft for obstruction of superior vena cava caused by benign disease

Nine patients had operations for obstruction of the superior vena cava with superior vena caval syndrome caused by benign disease. Three patients had fibrosing mediastinitis, four had fibrosing mediastinitis with caseous necrosis, one had thrombosis of the superior vena cava around a pacemaker electrode, and one had spontaneous thrombosis of the superior vena cava. Patients ranged in age from 25 to 68 years. All bypass operations were performed with a composite spiral vein graft constructed from the patient's own saphenous vein, split longitudinally and wrapped around a stent in spiral fashion. The edges of the vein were sutured together to form a large conduit ranging in diameter from 9.5 to 15.0 mm. Six grafts were from the left innominate vein and three grafts were from the internal jugular vein. The grafts were placed into the right atrial appendage in all except one case, in which the graft was to the distal superior vena cava. Follow-up extends from 1 to 15 years. One patient required reoperation at 4 days for thrombosis at the innominate vein-graft anastomosis. Resection of the anastomosis and reconstruction of the graft rendered the patient symptom free. Two grafts closed during the first year after operation. One patient had advancing fibrosing mediastinitis, and a second bypass graft from the external jugular veins remain patent. Another patient had recurrence of spontaneous venous thrombosis. Thus seven of nine grafts remain patent for up to nearly 15 years and all but one patient is free of superior vena caval syndrome. These data show that bypass of the obstructed superior vena cava with a spiral vein graft relieves superior vena caval syndrome and demonstrate long-term patency of the graft.     

Portal vein reconstruction using an internal jugular vein as a graft: Report of a case

We report the case of a 41-year-old man with pancreatic carcinoma invading the portal vein who was successfully treated by portal vein resection combined with pancreatoduodenectomy and reconstruction using an autointernal jugular vein. The internal jugular vein is an ideal graft for portal vein replacement because it has sufficient length, a well-matched diameter, and there is no venous insufficiency after unilateral resection. Nevertheless, this is the first report of portal vein reconstruction using the internal jugular vein as a graft.     

The influence of the Univent endotracheal tube on internal jugular vein cannulation

This prospective clinical investigation assessed the effect of placement of a Univent tube on the anatomy of the internal jugular veins and the success of cannulation of the left internal jugular vein. After obtaining informed consent, 48 adult patients were enrolled. Of these, 42 patients were eligible and were divided into two groups: Univent tube (group U, n=21) and wire enforced endotracheal tube (group C, n=21). The Univent tube group were having a left thoracotomy. Using horizontal ultrasound scans just above the thyroid gland, the internal jugular vein was visualized and measured before and after Univent placement. The number of needle passes necessary to cannulate the left internal jugular vein in the two groups was also compared. Univent tubes were associated with lateral displacement of the right carotid artery and internal jugular vein on the convex side of the Univent tube, with compression of the right internal jugular vein by the artery, resulting in a kidney-shaped cross-section of the vein. On the left (concave side of the tube), the neck was indented, the sheath of the left carotid artery was displaced medially, and the left internal jugular vein distorted to an ellipse. There was a significant increase in the lateral diameter and a decrease in the cross-sectional area of the left internal jugular vein (t-test, P < 0.05). The first attempt at cannulation of the left internal jugular vein failed significantly more often in the Univent group (13/21 vs 5/21 in group C, Chi-square 6.22, P=0.025). Cannulation of the internal jugular vein before placement of the Univent tube, or placement with ultrasound guidance is suggested.     

The use of internal jugular vein as interposition graft for femoral vein reconstruction following traumatic venous injury: a useful approach in selected cases

Complex venous injuries remain a controversial and interesting challenge to the vascular and trauma surgeon. Data from the Vietnam Vascular Registry, combined with experience from recent civilian series, seem to indicate that the best results are obtained when venous repair is undertaken. This is especially true of combined arterial and venous injury where compromised venous outflow may lead to limb loss in spite of patent arterial reconstruction. The larger size of veins, however, has required the construction of complex and time-consuming panel and spiral-vein grafts. This makes them far from ideal in the trauma treatment setting, where minimization of blood loss and operating room time are high priorities. We present a case of combined injury to both femoral artery and vein, where the femoral vein injury was repaired using autologous internal jugular vein as interposition graft while the arterial injury was repaired with autologous saphenous vein from the opposite limb. The avoidance of prosthetics, ease of harvest, size match, and little associated morbidity all make a strong case for use of the internal jugular vein where speedy reconstruction of large venous conduits is indicated.     

Cephalic pancreaticoduodenectomy with mesentericoportal venous reconstruction. Technical features

Cephalic pancreaticoduodenectomy (CPD) with mesentericoportal venous resection increases the resectability rate of pancreatic tumors. When performed in selected patients and by experienced surgical teams, this technique shows the same long-term rates of morbidity, mortality and survival as CPD without vascular resection, provided that negative surgical margins are obtained. This procedure is contraindicated by complete thrombosis of the portal or superior mesenteric veins, invasion of the superior mesenteric artery or celiac trunk, and distant or periaortic lymph node involvement. Venous reconstruction can be performed through lateral suture, termino-terminal anastomosis, or by graft placement. We believe that intercalation of the autologous internal jugular vein facilitates resection and minimizes phenomena of venous stasis. We present a case of adenocarcinoma of the pancreatic head infiltrating the superior mesenteric-portal vein confluence that underwent surgery in our hospital. CPD with mesentericoportal venous resection and reconstruction using autologous internal jugular vein were performed. The most important technical features are discussed.