Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors

The contraindication to curative excision of mediastinal and pulmonary cancers because of invasion of the superior vena cava is now challenged by the existence of vascular prostheses that are suitable for venous replacement. Between 1979 and 1990 22 patients underwent resection of lung cancer (n = 6) or malignant mediastinal tumors (n = 16) involving the superior vena cava. Resection was done with concomitant venous reconstruction, and polytetrafluorethylene grafts were used. All bronchogenic carcinomas necessitated right pneumonectomy, whereas the excision of mediastinal tumors had to include pulmonary resections in nine patients (five lobectomies and four sublobar resections) and the right phrenic nerve in 12 patients. Venous reconstruction was performed by interposition of a large polytetrafluoroethylene graft between the proximal and cardiac ends of the superior vena cava (n = 8), or between one (n = 10) or both brachiocephalic veins (n = 4) and the right atrium. One patient died postoperatively (4.5%), and another had mediastinitis that was successfully treated by omentopexy. Chemotherapy was administered preoperatively to five patients and postoperatively to seven patients; radiotherapy was administered to two and 10 patients, respectively. The overall actuarial survival rate is 48% at 5 years, with 11 patients presently alive. The survival rate of patients with mediastinal tumors is 60% at 5 years. Among the patients with lung cancer, two with N1 disease are alive at 16 and 51 months, and one died at 38 months; the two patients with N2 disease died at 6 and 8 months. Only one graft occlusion occurred in the postoperative period; another occurred 14 months after operation and was precipitated by insertion of a central venous catheter. The patency of all remaining grafts was demonstrated after an average time of 23 (1 to 98) months. On the basis of these results, polytetrafluoroethylene graft replacement of the superior vena cava should be part of the planning and execution of radical excision with curative intent of mediastinal and right pulmonary malignant tumors that are not present with other contraindications, such as pleural or distant metastasis and severe systemic disease.     

Replacement of the superior vena cava with polytetrafluoroethylene grafts combined with resection of mediastinal-pulmonary malignant tumors. Report of thirteen cases

From 1979 to 1986, we replaced the superior vena cava with polytetrafluoroethylene grafts in 13 patients to enable resection of malignant mediastinal or pulmonary tumors. Five prostheses could be interposed between a tumor-free proximal superior vena cava and right atrium while eight required separate innominate anastomoses (Y grafts constructed intraoperatively). There were no deaths. Phlebograms obtained 15 to 30 days after the operation demonstrated patency in 12 of 13 patients. Long-term (average 24 months) patency was evident in eight. Five patients are alive at 1, 3, 40, 49, and 60 months, a cumulative survival rate of 27% at 3 years.     

Significance of hepatic resection combined with inferior vena cava resection and its reconstruction with expanded polytetrafluoroethylene for treatment of liver tumors

BACKGROUND: Resection of the IVC is required when a liver tumor invading the IVC is completely removed. The purpose of this study was to evaluate the clinical significance of hepatectomy combined with IVC resection and reconstruction with an ePTFE graft for treatment of invasive liver tumors and to discuss the validity of this surgery. STUDY DESIGN: Eleven selected patients with liver tumors underwent various types of hepatectomy with retrohepatic IVC resection, followed by IVC reconstruction. The postoperative courses, clinicopathologic features of the tumors, operative procedures, and outcomes of the patients were studied. RESULTS: Ten of 11 patients did not require an active ventriculovenous bypass using a biopump. Invasion to the IVC was histologically proved in 9 of the 11 patients. After reconstruction, all artificial vessel grafts maintained patency throughout the observation period. Four patients are still alive with cancer-free status ranging from approximately 11 years to 5 months. One-year, 3-year, and 5-year survival rates were 63.6%, 38.2%, and 25.5%, respectively, with a 50% survival of 29 months. CONCLUSIONS: IVC resection and its reconstruction with ePTFE for treatment of liver tumors was safely performed on 11 selected patients with a 50% survival of 29 months. Patency of the graft was maintained for the longterm without infectious complications. This surgical procedure is indicated in some select patients in whom IVC invasion is extensive.     

Liver resection combined with excision of vena cava

BACKGROUND: This study was designed to review our experience with combined partial hepatectomy and vena caval replacement for primary and metastatic liver tumors. STUDY DESIGN: The medical records of all the patients who underwent liver resection and excision of the vena cava over a period of 13 years and 4 months at a single institution were analyzed. The types of tumors fell into four categories: 1) metastatic, 2) primary leiomyosarcoma of the inferior vena cava, 3) tumors with direct extension to the liver, and 4) cholangiocarcinoma. RESULTS: The perioperative mortality was 11% related to technical complications and hepatic insufficiency. Other important complications included biliary fistula and liver abscess; patients recovered from these complications without sequelae. Six of nine patients are alive with a followup from 6 months to 156 months (median 66.5 months), and three of them are free of disease. The most common sites of recurrence were lung, liver, and brain. The patients with leiomyosarcoma of the cava and pheochromocytoma who underwent these combined procedures had the longest survival. CONCLUSIONS: This small series confirms the feasibility of obtaining longterm survival after excision of tumors that have involved portions of the liver and the vena cava. Innovative variations on the method of vena caval replacement and increased awareness of these complex surgical techniques will expand the indications of hepatic resection.     

上腔静脉成形术在胸部恶性肿瘤治疗中的应用

目的探讨上腔静脉(SVC)置换或成形术治疗胸部恶性肿瘤侵及SVC患者的手术技术选择和麻醉管理特点。方法2000年1月至2006年10月行SVC成形或置换术治疗胸部恶性肿瘤侵及SVC患者73例,其中行肺切除(含支气管成形术) SVC成形/置换术42例;纵隔肿瘤切除 SVC成形/置换31例。直接修复21例,SVC阻断下补片修补22例,腔内引流技术下补片修补15例;人造血管置换15例。结果手术死亡3例。术后所有患者SVC梗阻症状于24～48h内明显缓解,未见脑部损害及严重并发症。随访6～42个月,随访率78.57%,3个月后再发SVC梗阻症状患者1例;1年和2年生存率分别为74.55%和58.19%。结论肿瘤侵及SVC给外科手术带来一定的难度和风险,合理恰当的外科手术技术和麻醉管理可保障SVC重建术安全实施,改善患者生存质量,延长生存时间。     

Superior vena cava reconstruction using heterologous pericardial tube after extended resection for lung cancer.

Superior vena cava (SVC) resection for lung cancer is feasible in selected patients, but the type of vessel reconstruction is still object of debate. We report a case of SVC revascularization successfully performed with heterologous 'custom-made' pericardial tube. This type of revascularization may improve the reconstruction of large mediastinal veins after their resection for malignancies.     

Superior vena cava syndrome

Superior vena cava syndrome is due to an intrinsic or extrinsic caval obstruction that evolves in acute or subacute way with distinctive clinical feature such as respiratory symptoms and venous stasis. Since 1998 we have treated three cases of spontaneous superior vena cava thrombosis in neoplastic patients who underwent several infusion of chemotherapy, respectively for a breast, uterine and rectum cancer. All patients was female, 52, 58 and 70 years old. The first two cases was treated with locoregional thrombolysis by infusing Urokinase 50,000 UI/h during 24 hours and Urokinase 50,000 UI/h during 12 h the third one. After that, we have positioned a 16/9 wallstent: in the first two cases directly into the superior vena cava, in the third case in the subclavian-anonyma truncus. We had in all cases the complete opening of the stent within the first 48 hours without complications, enabling us to reach a free caval diameter of about 2 cm with resolution of the clinical signs. In patients with high surgical risk, the caval wall-stent is the first choice to solve the vein recanalization.     

肾脏恶性肿瘤并静脉转移的外科治疗

目的：探讨肾脏恶性肿瘤并发静脉内转移的外科治疗方法及预后。方法：报告10例肾脏恶性肿瘤，其中肾细胞癌6例，肾母细胞瘤2例，肾盂癌1例，肾平滑肌肉瘤1例。肾静脉内转移4例，肝下型腔静脉转移5例，肝后和肝上的腔静脉内转移1例。在根治性切除患肾的同时阻断瘤栓上下的腔静脉和对侧肾静脉，完整取除瘤栓，腔静脉壁受累者同时切除腔静脉壁，术后辅以免疫治疗和放射治疗。结果：随访7年，平均5年生存率40％，肾母细胞瘤生存期小于3年，腔静脉壁受累者生存期小于1年，并发区域淋巴结转移者5年生存率33％。结论：手术切除静脉内转移癌是提高患者生存期的惟一手段，其预后取决于原发癌肿的性质和癌栓是否完全切除，而与癌栓的位置无直接相关。静脉内肿瘤转移同时并发腔静脉壁受累或区域淋巴结阳性的患者预后较差。     

Superior vena cava reconstruction using bovine jugular vein conduit.

The glutaraldehyde-treated bovine jugular vein conduit (BJVC) is a xenograft conduit initially used for right ventricular outflow tract reconstruction and has never been used for reconstruction of superior vena cava (SVC). In September 2003, a patient with SVC obstruction underwent SVC reconstruction using BJVC. He has been alive for 42 months and free from signs and symptoms of SVC obstruction except that metastasis was found in the vertebrae. The radionuclide venography showed the graft tube was patent and only slight stenosis was found in the proximal anastomosis. The initial result supports BJVC as an acceptable alternative for SVC reconstruction.     

Superior vena cava and innominate vein reconstruction in thoracic malignancies: single-vein reconstruction

Benign or malignant disease processes involving the superior vena cava can be resected and reconstructed with excellent perioperative results and sustained durability.