Endovascular occlusion of right to left arteriovenous shunt associated with persistent left superior vena cava

Left-sided superior vena cava (SVC) as the result of persistence of the left superior cardinal vein in postnatal life is a rare congenital anomaly, is usually associated with other cardiac defects, and can cause symptoms of right to left shunt. We report the case of a 58-year-old Asian man with a history of end-stage renal disease and Ebstein anomaly that was corrected surgically who presented with progressively worsening disabling dyspnea. An echocardiogram with concomitant intravenous saline injection raised the suspicion of right to left shunt, a finding that was confirmed with contrast injection of the left SVC that rapidly filled the left heart chambers and subsequently the aortic arch. To treat this anomaly, we accessed the left basilic vein under ultrasound guidance and inserted a 14F sheath into the left subclavian vein. A covered stent was then prepared at the back table with three Prolene 4-0 sutures that were wrapped around the middle portion of the graft to achieve a controlled area of stenosis after deployment. The stent graft was placed along the proximal innominate vein and the contiguous part of the left SVC. Coil embolization was then performed with coils that were positioned at the stenotic area of the covered stent. An immediate venogram demonstrated residual flow into the left SVC; however, a delayed venogram 2 weeks after the procedure showed occlusion of the left SVC and the development of collaterals to the right innominate vein that was draining to a normal right SVC. The patient remained marginally hypotensive after surgery, but he soon noted a substantial improvement in his symptoms. A repeat echocardiogram with intravenous saline injection confirmed the correction of the right to left shunt. Endovascular repair of persistent left SVC is feasible and safe and can be performed with minimal morbidity.     

胸部肿瘤侵及大血管时的手术处理

目的 总结64例胸部肿瘤浸润大血管手术时的处理经验，分析上腔静脉（SVC）手术技术及指征以及肺动脉袖状切除的适应证。方法 回顾性分析1991年1月至1999年6月64例胸内大血管受到肿瘤浸润患者的手术经验。受侵血管包括肺动脉根部和（或）肺动脉干、上静脉和（或）下肺静脉根部、SVC和（或）无名静脉。结果 24例接受了不同类型的SVC手术，包括左及右无名静脉分别与右心房人工血管搭桥术1例、左无名静脉与右心房人工血管搭桥4例、右无名静脉与右心房搭桥3例、奇青脉切除并SVC部分切除11例、单纯SVC部分切除5例。SVC置换或搭桥除1例应用涤纶血管者外，其余均是Gore-Tex人工血管，5例部分切除者使用了缝合器，41例肺动脉部分或袖状切除（肺动脉袖状并支气管袖状成形4例）、左心房部分切除13例，应用肺血管阻断或临时架桥术，所有手术均成功进行，无手术死亡，无严重并发症。SVC切除后生存时间最长者已达15年，为1例恶性畸胎瘤患者，肺癌切除SVC、无名静脉搭桥患者术后生存最长者已达5年。结论 大血管包括SVC及肺血管阻断与成形技术以及SVC置换术，是根治性切除浸润大血管的胸部肿瘤的关键性技术，正确及时地应用可以提高根治性切除率和安全性，减少探查率。     

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.     

Reconstruction of nonconfluent pulmonary artery using the retroaortic innominate vein for a single ventricle

The innominate vein usually courses anterior to the aortic arch, where it joins the right brachiocephalic vein to form the superior caval vein. A retroaortic innominate vein is an uncommon finding in patients with congenital heart disease. We report a patient with a single ventricle, single atrium, pulmonary atresia, nonconfluent pulmonary artery, persistent left superior caval vein, absent inferior caval vein (azygos connection), right aortic arch, and retroaortic innominate vein. His innominate vein took an anomalous course. The right brachiocephalic vein crossed from right to left underneath the aortic arch and formed a left superior caval vein with the left brachiocephalic vein and the azygos vein. We reconstructed the nonconfluent pulmonary artery using the retroaortic innominate vein and then performed a total cavopulmonary shunt when he was 32 months of age. Thereafter, a total cavopulmonary connection was carried out at age 42 months.     

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.     

Case of symptomatic subacute in-stent thrombosis after carotid angioplasty and stenting for severe carotid stenosis

We report a case of symptomatic subacute in-stent thrombosis after carotid artery angioplasty and stenting (CAS). The patient was a 72-year-old man who had severe asymptomatic right carotid artery stenosis. He received CAS with distal protection, and gained 100% opening of the right carotid artery. The administration of dual antiplatelet therapy (Aspirin 100 mg/day+Cilostazol 100 mg/day), which had been given since two weeks before the procedure, was continued afterwords. On the seventh day after the stent placement, the patient showed sudden onset of left hemiparesis and conjugated deviation of both eyes to the right side and followed by falling into a comatose state. Emergency angiography showed near occlusion of the right carotid artery, suggesting subacute in-stent thrombosis. In conjunction with the intravenous administration of tissue plasminogen activator (1300,000 IU), we performed additional stent placement on the stented portion of the ICA and gained full recanalization of the ICA about three hours after the onset of the symptoms. The patient showed rapid recovery and returned home with slight clumsiness of his right hand. Symptomatic subacute in-stent thrombosis after CAS is a rather rare complication. We discuss on the possible cause of this and stress the necessity of an additional emergency stenting to gain rapid recanalization.     

A giant neuroendocrine tumor of the thymus gland causing superior vena cava syndrome

We describe the case of a 37-year-old man with a rare giant thymic neuroendocrine tumor. The patient presented with a swelling of the neck associated with superior vena cava syndrome and underwent stent implantation in the right innominate vein (brachiocephalic vein). Computed tomography imaging revealed a large tumor of the mediastinum, measuring 15?×?10?×?12?cm. CT-guided core-needle biopsy for histology revealed a thymic carcinoid. Surgical resection of the tumor and repair with interposition of a 14-mm Gore-Tex prosthesis between the left innominate vein and the right atrial appendage were performed. Histopathological analysis classified the tumor as an atypical thymic carcinoid. Postoperative course was uneventful. Since complete resection could not be achieved, the patient received two cycles of peptide-receptor radionuclide therapy followed by conventional radiotherapy, and remains symptom-free at 12?months after surgery.     

A case of malignant lymphoma of anterior mediastinum requiring superior vena cava reconstruction]

The patient was a 21-year-old female with malignant lymphoma of the anterior mediastinum, which was associated with superior vena cava (SVC) syndrome due to tumor invasion and tracheo-bronchial stenosis due to tumor compression. The bilateral brachio-cephalic vein and superior vena cava were resected with the tumor, and SVC reconstruction with a ringed expanded polytetrafluoroethylene (EPTFE) graft was performed between the right brachio-cephalic vein and SVC, and between the left brachio-cephalic vein and the right appendage. Postoperative anti-coagulant therapy was not performed. Postoperatively, SVC syndrome and the complaint of tracheo-bronchial stenosis disappeared promptly. Venography, which was performed 2 weeks postoperatively, presented patency between the right brachio-cephalic vein and SVC, but the graft between the left brachio-cephalic vein and the right appendage was obstructed. SVC reconstruction using a ringed EPTFE graft is considered to be significant for the improvement of resectability and the relief of clinical symptoms.     

Superior vena cava perforation and cardiac tamponade after filter placement in the superior vena cava--a case report

The purpose of this paper is to report the complication of perforation of the superior vena cava (SVC) leading to cardiac tamponade after the insertion of a Trapease IVC filter in the SVC position. A 29-year-old man was hit by motor vehicle and sustained numerous injuries including a left skull fracture, intracerebral hemorrhage, and left open tibial shaft fracture. During his hospitalization, he developed an extensive symptomatic right upper extremity deep venous thrombosis involving the brachial, axillary, subclavian, internal jugular, and brachiocephalic veins. Owing to an intracerebral bleed, anticoagulation was contraindicated. Therefore, a Trapease filter (Cordis Inc.) was placed in the SVC via the left subclavian vein. Four hours later, the patient became hypotensive with associated tachycardia and tachypnea. Computed tomography of his chest revealed a hematoma around the SVC, a moderate amount of fluid within the pericardium, and a moderate-sized right pleural effusion. The patient was taken to the operating room and a pericardial window was performed. Approximately 500 cc of blood was evacuated from the pericardium and immediate improvement in vital signs was noted. The patient was discharged from the hospital 2 weeks later and at 6-month follow-up had made full recovery. This is the first case of SVC perforation leading to cardiac tamponade after the insertion of a Trapease filter. Owing to the rigid structure of the filter and associated motion of the SVC and pericardium, the Trapease filter may be contraindicated in the SVC.     

Innominate vein-right atrial bypass for relief of superior vena cava syndrome due to pacemaker lead thrombosis

We present a patient with superior vena cava (SVC) obstruction due to multiple intraluminal pacemaker leads. Previous attempts at balloon dilatation of the SVC and surgical angioplasty did not provide a long-term solution. A Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ, USA) conduit interposed between the innominate vein and right atrial appendage has resulted in symptomatic relief at a follow-up of 6 months.     

Superior vena cava obstruction: bypass using spiral vein graft.

BACKGROUND: Previous midterm experience with the composite spiral saphenous vein graft to bypass the obstructed superior vena cava (SVC) has been favorable. This study looks at the long-term results in patients followed for up to 23 years. METHODS: Sixteen patients aged 17 to 68 years had operation for obstruction of the SVC with SVC syndrome caused by benign disease. Eleven patients had fibrosing mediastinitis with or without caseous necrosis, 4 had thrombosis caused by a catheter or a pacemaker electrode, and 1 had spontaneous thrombosis. All operations were performed using a composite spiral vein graft constructed from the patient's own saphenous vein. Graft diameter ranged from 9.5 to 15.0 mm. Ten grafts were from the left innominate vein, and six grafts were from the right or left internal jugular vein. The grafts were placed to the right atrial appendage in all patients except 1. Follow-up extends from 1 month to 23 years 8 months (mean follow-up, 10.9 years). RESULTS: Fourteen of 16 grafts remain patent for up to 23 years, and all patients but 1 are free from SVC syndrome. One patient required revision of the graft for thrombosis 4 days after operation. Two grafts closed during the first year after operation: one because of recurrence of spontaneous venous thrombosis and the other because of aggressive fibrosing mediastinitis requiring operation for graft revision three times over a 12-year period prior to death. CONCLUSIONS: These data demonstrate that a spiral vein bypass graft for treatment of the obstructed SVC relieves SVC syndrome and has excellent long-term patency.     

Severe outflow block syndrome caused by compression by the swollen caudate lobe after living donor liver transplantation: report of a case

A 50-year-old man with primary biliary cirrhosis underwent living-donor liver transplantation (LDLT) using a graft of a left hemiliver with a left caudate lobe and duct-to-duct hepaticocholedochostomy. Postoperative bile leakage necessitated percutaneous drainage 22 days after LDLT. The patient presented to our hospital 205 days after the LDLT with abdominal distension and fever. Computed tomography showed ascites and a diffusely mottled pattern in the graft. The caudate lobe was swollen, and its bile ducts were dilated. The inferior vena cava was forced to the right by the swollen caudate lobe, and the root of the hepatic vein was stretched. The hepatic vein was not contrasted. Endoscopic retrograde cholangiography showed a biliary anastomotic stricture. Based on these findings, we diagnosed a severe outflow block of the hepatic vein and biliary anastomotic stricture. We performed balloon dilation of the biliary anastomosis and implanted a metallic stent in the hepatic vein. Thereafter, his clinical symptoms improved dramatically.     

Post aortic left innominate vein in a patient with a surgically corrected double outlet right ventricle]

We report the presence of a post aortic left innominate vein (PALIV) in a patient with a surgically corrected double outlet right ventricle. A 30-year-old male was admitted to our hospital with exertional dyspnea. The patient had undergone right ventricular outflow tract reconstruction and closure of ventricular septal defect at the age of 14. Echocardiography and cardiac catheterization showed severe pulmonary regurgitation and a residual ventricular septal shunt. After resternotomy, right ventricular outflow tract reconstruction and residual shunt closure were performed. During the operation, the left innominate vein was not found in front of the aorta. Postoperative cardiac catheterization and computed tomography showed that the left innominate vein was positioned behind the ascending aorta draining to the superior caval vein.     

Use of the internal mammary vein for access outflow in a hemodialysis fistula

A patient with occlusion of multiple central veins from both dialysis and nondialysis catheters required permanent access for hemodialysis. Magnetic resonance imaging showed a patent left innominate vein. He underwent creation of a left axillary artery to internal mammary vein transposition fistula using the basilic vein from his right arm. The fistula has required one revision for outflow stenosis and one for aneurysmal degeneration. It continues to function well 3 years after placement. The internal mammary vein is an option for outflow when permanent hemodialysis access has failed in the presence of a patent innominate vein with occluded or severely stenotic ipsilateral subclavian and jugular veins.     

Prosthetic replacement and tangential resection of the superior vena cava in chest tumors

AIM: Infiltration of the superior vena cava (SVC) due to advanced non small cell lung cancer (NSCLC) or thymoma can be treated by prosthetic replacement or tangential resection. These two technical procedures and their results are described. METHODS: From 1988 to 2002, we performed 37 SVC resections: 21 replacements with polytetrafluoroethylene (PTFE) prostheses and 16 tangential exereses. Sixteen patients affected by locally advanced NSCLC (12 T4; 4 extracapsular N2) and 5 subjects with thymoma (Stage III Masaoka) underwent prosthetic replacement of the SVC. After neoadjuvant polychemotherapy, tangential resection was performed on 12 patients with extracapsular N2 NSCLC, and in 1 patient with T4 and in 3 patients with T3a disease. We performed prosthetic replacement in 18 cases using a straight prosthesis (?18-20 mm). A bridge (10-14 cm) between the innominate vein and the right atrium was created in 3 patients. The main indication for a prosthetic replacement was infiltration of more than 30% of the circumference of the SVC. There were 4 thromboembolic complications (19%), with one intraoperative death (4.8%). Tangential resection of the SVC for infiltration <20% was performed both manually and with staplers (double clamping) without any major complications. RESULTS: Mean survival was 23 months in those patients who had undergone PTFE replacement for T4 lung cancer and for thymoma. Mean survival was 15 months in those who had undergone tangential resections for NSCLC with extracapsular N2. We performed restaging of the tumor using chest angio-CT scan in 11 patients, one year after the operation. We found 80% patency in 7 SVC prostheses and 50% patency in 4 others: the two bridges between the left innominate vein and the right atrium appeared to be partially closed but were compensated by important collateral circles. CONCLUSION: SVC replacement, associated with pulmonary resection or removal of mediastinal masses, can be performed in selected cases. It should not be considered as palliative treatment because of the important perioperative risks. SVC tangential resection involves fewer surgical problems. However, since this procedure is used mostly for N2 NSCLC subjects, patients have a low mean survival in spite of adjuvant therapy.     

Bilateral Mediastinal Lymphangiohemangiomas Containing Anomalous Venous Components - A case report -

Lymphangiohemangiomas of the mediastinum are exceedingly rare and few cases have been published in the English literature. This report may be the only reported case in which lymphangiohemangiomas were found bilaterally. We report a case of a 7-year-old boy with an incidental finding of an abnormal mediastinal shadow on a chest X-ray. The chest CT showed a large mass in the left superior mediastinum and another in the right posterior mediastinum. The left mass had anomalous venous channels connected to the left innominate vein, and the right mass to the left atrium. We performed an excision of the mass in the left side first and then the right side one month later. Anomalous venous channels were dissected carefully and ligated. There were no complications and no signs of recurrence 30 months after the operation.     

Successful surgical treatment of total left anomalous pulmonary venous return with intact atrial septum--a case report

A successful repair of total left anomalous pulmonary venous return with intact atrial septum is reported. A 7-year-old girl was admitted for evaluation of cardiac murmur which was first noted at 3 months of age. She had been followed up on suspicion of ASD, without any subjective symptoms. Physical examination on admission revealed a systolic ejection murmur at left sternal border. Chest X-ray showed mild cardiomegaly and increased pulmonary vascularity. ECG showed right axis deviation and incomplete right bundle branch block. Selective pulmonary arteriography delineated anomalous return of all left pulmonary veins to RA via vertical vein, left brachiocephalic vein, and SVC, and documented the absence of an atrial septal defect. Ratio of pulmonary to systemic blood flow was 2.2. Vertical vein was anastomosed to left atrial appendage under cardiopulmonary bypass. Postoperative cardiac catheterization showed no difference of wedge pressure between bilateral PA. The patient is up and well 1 years and 6 months after operation.     

Upper extremity thromboembolism after axillary-axillary bypass grafting

Two patients experienced upper extremity thromboembolism after axillary-axillary bypass grafting (AxAG) for symptomatic subclavian artery stenosis. The first patient, a 67-year-old male, presented with left upper extremity thromboembolism 3 years after AxAG with 8 mm externally support PTFE. An arteriogram revealed a patent AxAG, thrombus in the proximal left subclavian arterial stump just distal to its occlusion, and multiple digital artery emboli. The patient was treated with warfarin for 8 months, with resolution of symptoms. The second patient, a 57-year-old male, occluded his AxAG (8 mm knitted Dacron) with minimal return of symptoms. Non-operative treatment was elected and 4 years later the patient presented with right upper extremity (donor side) thromboembolism. Arteriography revealed occlusion of the AxAG, radial artery, and digital arteries of the index, long and ring fingers. Thrombolytic therapy of the right arm was undertaken with minimal improvement. Subsequent detachment of the AxAG and placement of an interposition reversed saphenous vein graft was performed. Both patients continue to be asymptomatic during follow-up of 4.7 and 2.0 years, respectively.     

A dumon stent inserted for bronchial stenosis causing a left bronchopericardial fistula: Report of a case

We present herein the case of a 59-year-old man in whom a Dumon stent, inserted as treatment for stenosis of the left main bronchus, caused a left bronchopericardial fistula. The patient initially presented with severe dyspnea caused by main bronchial stenosis of unknown origin for which a Dumon stent was inserted at a local hospital. The Dumon stent migrated to the endobronchus through the stenosis of the left main bronchus a few days later, and his dyspnea remained unresolved. He was subsequently referred to our department 6 months later, where a left pneumonectomy under supportive cardiopulmonary bypass through the femoral artery and vein was performed, and a postoperative pathological diagnosis of bronchial leiomyosarcoma was made. For this rare group of malignant tumors, early diagnosis permits complete surgical resection of the mass and offers the best prognosis. Excision of the tumor should be performed under cardiopulmonary bypass through the femoral vessels when a risk of sudden rupture of the pulmonary artery or vein exists for any reason.     

经腹腔干-胃十二指肠弓逆向介入治疗肠系膜上动脉开口处完全闭塞无残端病变1例

目的:探讨逆向入路支架植入治疗肠系膜上动脉(SMA)闭塞的技术。方法:回顾2017年2月1例于复旦大学附属中山医院血管外科行逆向开通SMA闭塞的患者临床资料。结果:患者为47岁女性,诊断为SMA闭塞引起的慢性肠系膜缺血(CMI),行腔内治疗再通SMA。由于SMA开口处完全闭塞性,无残端,经肱动脉和股动脉双侧入路均无法开通病变部位。利用腹腔干和SMA之间的胃十二指肠弓,通过此通路逆向开通SMA闭塞处;肱动脉入路导管和导丝对接后顺利正向通过病变,完成球囊扩张和支架植入术。术后患者CMI症状消失,3个月后随访CTA显示,支架定位良好,远端血管通畅。结论:对于常规血管内介入治疗方法失败的SMA闭塞患者,通过有效的侧支通路进行逆行开通是可行的。