Mediastinoscopy in Advanced Superior Vena Cava Obstruction

Superior vena cava syndrome can be a rapidly progressive, lethal process that is caused by a malignancy in 92 to 94% of cases. Since all effective therapy is inherently harmful, it would be reassuring to have a definitive tissue diagnosis before initiating treatment. Because easily accessible tissue is not always available, mediastinoscopy must be relied on to confirm the diagnosis in some patients.Twenty-nine patients with advanced superior vena cava syndrome were reviewed. Fifteen of them required mediastinoscopy to confirm the diagnosis, since lesser procedures, i.e., bronchoscopy, needle biopsy, and sputum cytology, were negative for malignant tissue. Contrary to reports in the literature, mediastinoscopy can be performed safely in patients with advanced superior vena cava syndrome and can yield a definitive diagnosis in each.     

Extracorporeal Venous Bypass: A Beneficial Device in Operation for Superior Vena Caval Syndrome

Life-threatening complications can occur unexpectedly during general anesthesia in operations for acute progressive superior vena caval syndrome. We describe a temporary extracorporeal axillofemoral venous bypass procedure to reduce the high venous pressure in the upper part of the body before induction of general anesthesia. The bypass supports the operation for superior vena caval syndrome without life-threatening accidents. No serious complications related to the procedure have been observed.     

Anomalies of the Superior Vena Caval Flow Pattern in Patients with Tricuspid Insufficiency

An intra-operative method, based on simultaneous superior vena caval (SVC) flow pattern recording and right atrial and ventricular pressure registrations, has been used in 20 cases of tricuspid insufficiency (TI), of which 19 accompanied mitral and aortic/mitral valve disease. The method detects TI easily and provides quantitative information about TI. According to the flow tracings, TI has been classified in three groups: Severe TI = SVC reflux 30%; moderate TI=15% > SVC reflux > 30%; and slight TI = SVC reflux > 15%. A characteristic flow profile was found in the group with severe SVC reflux. The flowmetric findings correlate well with the cine-angiographical classification of TI. The mean values of right atrial and ventricular pressures were significantly higher than normal, but there was no correlation between the percentage of reversed flow and pressures, except in the cases with slight reflux. Flow measurements were also performed with advantage after extra-corporeal bypass in cases undergoing tricuspid valve replacement and annuloplasty. The method provides more reliable and accurate information about the tricuspid valve function than do the conventional examinations. This method should make it easier to compare the results of various surgical and conservative treatments of different degrees of TI.     

Repair of Superior Vena Caval Perforation during Pacemaker Placement with Video-Assisted Limited Thoracotomy

Abstract We report a case of a patient who sustained superior vena cava perforation just proximal to the innominate-caval confluence during pacemaker implantation. Because this complication was recognized early and the dilator was left in place, the patient remained hemodynamically stable and successfully underwent a videoscopically assisted repair of the superior vena caval perforation through a limited thoracotomy incision.     

The Sequelæ of Inferior Vena Caval Interruption

Recurrent pulmonary emboli occurred in 26 of 85 patients (31%) after inferior vena caval interruption to prevent pulmonary emboli. Sequela following this procedure included early problems associated with bleeding, venous thrombosis, the sequestration syndrome, and death. Late sequela were recurrent episodes of venous thrombosis, the post-phlebitic syndrome and recurrent emboli. Inferior vena caval interruption is associated with significant continuing disability, and it fails to solve the problem it was designed to prevent.     

Influence of Superior Vena Caval Zone Condition on Cyclic Changes in Right Ventricular Outflow during Respiratory Support

Background : Adequate fluid resuscitation in critically ill patients undergoing mechanical ventilation remains a difficult challenge, and diastolic and systolic right ventricular (RV) changes produced by positive airway pressure are important to consider in an individual patient with inadequate circulatory adaptation during respiratory support. We hypothesized that insufficient thoracic vena cava filling, predisposing to inspiratory collapse (zone 2 condition), may transiently affect RV outflow.

Methods : We measured beat-to-beat superior vena caval diameter and Doppler RV outflow during a routine transesophageal echocardiographic examination in 22 patients undergoing mechanical ventilation, all of whom required hemodynamic monitoring, and we calculated a collapsibility index for the superior vena cava as maximal expiratory diameter minus minimal inspiratory diameter, divided by maximal expiratory diameter.

Results : In 15 patients (group 1), the collapsibility index was low (17 +/- 7%) and was associated with a moderate inspiratory decrease in RV outflow (25 +/- 17%). However, in seven patients (group 2), we observed a high collapsibility index (71 +/- 7%), which was associated with a major inspiratory decrease in RV outflow (69 +/- 14%) combined with a reduced pulmonary artery flow period. A rapid volume expansion, only performed on group 2, markedly and significantly reduced both the collapsibility index (15 +/- 12%) and the inspiratory decrease in RV outflow (31 +/- 20%).     

Surgical Relief of Thrombotic Superior Vena Cava Obstruction Caused by Endocardial Pacing Catheter

Superior vena cava obstruction, an uncommon thrombotic complication of transvenous endocardial pacing, can usually be managed with long-term anticoagulation therapy. In a 55-year-old woman with a permanent pacemaker, progressive obstruction of the superior vena cava developed despite nine months of warfarin sodium therapy. Relief was obtained by interposing a spiral vein graft from the left internal jugular vein to the right atrium. The literature is reviewed, and recommendations are made for management of this unusual problem.