- Email: [email protected]
Malignant obstruction of the superior vena cava and its palliation
Malignant obstruction of the superior vena cava and its palliation Report offour cases Four cases of obstruction of the superior vena cava caused by inoperable bronchogenic carcinoma are presented in which the signs and symptoms were disabling. Palliation was achieved by placing a 10 mm. Dacron prosthetic bypass graft between the left innominate vein and the right atrial appendage, resulting in prompt relief. All patients were given warfarin for anticoagulation and subsequently deep x-ray therapy and diuretics were added. There was no operative or hospital death or morbidity. Two of the patients died of distant metastases at 14 and 6 months, respectively, postoperatively. The other two are alive and well at II and 5 months after the operation. Venous obstruction has not recurred to date in any of the four patients. A relevant review of the literature has been made.
Ram Bandhu Avasthi, M.B., B.S., F.R.C.S. (Eng. and Edin.), and Keyvan Moghissi, F.R.C.S., Cottingham, England
T
he commonest cause of obstruction of the superior vena cava is malignancy. Usually the treatment is difficult and results are disappointing. In our department four such cases were treated by palliative surgery and they are discussed here.
Case reports CASE I. K. C., a 51-year-old housewife, was first seen on Dec. 17, 1974, having had signs and symptoms of superior vena caval obstruction for 3 weeks. She smoked 10 to 15 cigarettes a day. Results of routine laboratory investigations were normal. A chest roentgenogram (Fig. I, left) showed an opacity in the right upper zone compatible with enlarged paratracheal glands. Results of bronchoscopy and right scalene fat biopsy were normal. Venous angiography (Fig. 1, center) showed almost total occlusion of the superior vena cava. On Dec. 31, 1974, a median sternotomy was performed with a view to resection and grafting of the superior vena cava. There was a hard mass along the whole length of the superior vena cava, causing its obstruction and invading the trachea, paratracheal glands, the hilum of the right lung, and its main pulmonary artery. Finger exploration through the
From the Department of Cardiovascular and Thoracic Surgery, Castle Hill Hospital, Cottingham, N. Humberside, England. Received for publication Dec. 29, 1976. Accepted for publication March II, 1977. Address for reprints: Mr. Ram Bandhu Avasthi, Thoracic Surgical Unit, City Hospital, Greenbank Drive, Edinburgh EHIO 5SB, U. K.
244
right atrial appendage confirmed almost total obstruction of the superior vena cava. Biopsy of this mass revealed anaplastic small cell bronchial carcinoma. The tumor was obviously unresectable. A 10 mm. diameter Dacron graft was inserted obliquely, end-to-side, between the left innominate vein and the right atrial appendage. This procedure dropped the central venous pressure from 35 to 12 ern. H 20 immediately after placement of the bypass graft. Recovery was uneventful. Within 24 hours the symptoms and signs of superior vena caval obstruction had abated, and the prominent chest wall veins were invisible after 2 days. Warfarin was given for anticoagulation. At 17 days, a venous angiogram confirmed the graft's patency. At 5 weeks deep x-ray therapy was commenced. At 15 weeks the patient was asymptomatic, there was no evidence of venous obstruction, and the chest x-ray film was normal (Fig. 1, right). She had been well for 12 months when metastases appeared, and she died at home 14 months postoperatively. Permission for autopsy was refused. At no time was venous obstruction present after the operation. CASE 2. F. W. P., a 58-year-old male security officer, was first seen on Jan. 22, 1976, with cough, dyspnea, poor appetite, signs and symptoms of superior vena caval obstruction, and stridor. A chest roentgenogram (Fig. 2, left) showed an opacity in the right upper zone and right hilum and a raised diaphragm. Bronchoscopy revealed obstruction of the right main bronchus owing to squamous cell carcinoma. Venous angiography showed (Fig. 2, center) obstruction of the superior vena cava and collaterals, via azygos and hemiazygos systems, to the inferior vena cava. On Feb. 2, 1976, a median sternotomy was carried out. A large tumor in the superior mediastinum, involving major structures around
Volume 74 Number 2
August.19n
Obstruction of superior vena cava
245
Fig. 1. Case I: Left, Preoperative chest roentgenogram. Center, Roentgenogram of superior vena cava. Right, Postoperative chest roentgenogram .
Fig. 2. Case 2: Left. Preoperative chest roentgenogram. Center, Roentgenogram of superior vena cava. Right, Postoperative chest roentgenogram .
it, was assessed unresectable. A 10 mm. Dacron graft was inserted end-to-side between the left innominate vein and the right atrial appendage. Recovery was uneventful, and within 24 hours the signs of superior vena caval obstruction had started to improve. The patient was given warfarin and a diuretic. Two weeks later deep x-ray therapy was commenced. At 7 weeks a venous angiogram showed partial obstruction of the graft with only a narrow channel through it. Eight months later the patient was doing well and had no signs of venous obstruction (Fig . 2, right). C ASE 3. H. S., a 61-year-old male welder, was first seen on March 29, 1976, having had signs and symptoms of superior vena caval obstruction, along with dyspnea , tightness in the chest, and weight loss, for 2 months. He had finger clubbing. A chest roentgenogram (Fig. 3, left) showed a wide mediastinum. Bronchoscopy showed a broad carina , narrow right upper lobe orifice, but no intrabronchial tumor. Venous angiography (Fig. 3, center ) showed displacement and infiltration of both innominate veins and almost complete obstruction of the superior vena cava . Collaterals via azygos
and hemiazygos systems were present. On May 16, 1976, a median sternotomy was performed. A tumor in the superior mediastinum, involving the superior vena cava, right bronchus, thymus, and distal parts of both innominate veins, on histology proved to be a moderately well-differentiated squamous cell carcinoma of bronchial origin. A 10 mm. endto-end Dacron graft was placed between the left innominate vein and the right atrial appendage . The signs of superior vena caval obstruction disappeared in a week. Recovery was satisfactory . The patient was given warfarin and a diuretic. Deep x-ray therapy was commenced at 2 weeks , and at 5 weeks he was discharged home , fit and well (Fig . 3, right). He was readmitted 3 months later with dysphagia owing to external compression of the esophagus ; this improved with esophageal dilatation. At 5 months he was readmitted with metastases and died in the hospital a month later. Postoperative venography was unsatisfactory for technical reasons . Permission for autopsy was refused . CASE 4 . G . E., a 61-year-old housewife, was seen on July 7, 1976, having had cough, sputum , dyspnea , and signs and
The Journal of
246 Avasthi and Moghissi
Thoracic and Cardiovascular Surgery
Fig. 3. Case 3: Left, Preoperative chest roentgenogram. Center. Roentgenogram of superior vena cava. Right. Postoperative chest roentgenogram.
Fig. 4. Case 4: Left. Preoperative chest roentgenogram. Center, Roentgenogram of superior vena cava. Right. Postoperative chest roentgenogram. symptoms of superior vena caval obstruction for 3 weeks. She had been a heavy smoker for many years. A chest roentgenogram showed a right hilar opacity (Fig. 4, left). Bronchoscopy revealed a narrowed right upper lobe orifice, and a blind biopsy was negative for malignancy. Venous angiography (Fig. 4, center) showed complete obstruction of the superior vena cava just above the right atrium. On July 14, 1976, a median sternotomy was performed. A large tumor in the right side of the superior mediastinum, involving the right main bronchus, the origin of the main pulmonary artery, and the thymus, histologically proved to be a large cell anaplastic bronchial carcinoma, assessed as inoperable. Exploration of the left innominate vein showed this to be filled with fragments of tumor tissue and blood clots, which were removed with ease. A 10 mm. Dacron graft was inserted end-to-side between the left innominate vein and the right atrial appendage. Recovery was uneventful and there was a dramatic relief of superior vena caval obstruction. The patient
was given warfarin and a diuretic. Two weeks later, deep x-ray therapy was started. Ten weeks later she was doing well and fully active (Fig. 4, right).
Discussion The incidence of bronchogenic carcinoma is increasing progressively, 12-14 and 75 to 90 percent of the cases of obstructed superior vena cava are due to this condition, a fact supported by many. 3-5, 16. 18 The Brompton Hospitalf reported that 14 percent of patients with bronchial carcinoma develop superior vena caval obstruction; this figure was 4.6 percent in a review of 4,000 cases by Le Roux.? Clamping of the superior vena cava for resection and replacement can have a high mortality rate, but its partial excision has been
Volume74 Number 2 August, 1977
carried out by Lowe and Bush.>' On the other hand, to have a good bypass for superior vena caval obstruction, certain graft properties should be considered, e.g., nonthrombogenic surface, lumen rigidity to resist external pressure, good sutureline to prevent stricture at the anastomotic site, graft lumen larger than the host vessel diameter, and good flow rate and pressure to keep the graft patent. It is difficult to achieve all these requisites, and therefore thrombosis of the graft, immediately and later postoperatively, is not uncommon. Most workers usually use deep x-ray therapy for palliation of this eondition'{- 13. 16. 17. 20 and many others. Some have used synthetic grafts to bypass this condition!- 6. 8. 19 with supportive results. In our group all four patients had severe signs and symptoms of superior vena caval obstruction, necessitating some form of treatment. We chose surgical bypass for palliation for prompt relief. The improvement was significantly remarkable and quick in cases 1 and 4. None of the patients had recurrence of venous obstruction at any stage following the operation. The first patient was fit and well for 12 months and died at 14 months. The third was well for 3 months, then had dysphagia, which was improved by simple dilatation, and died at 6 months with metastases. Patients 2 and 4 are doing well. Graft patency was satisfactory in the first case and partial in the second; technical difficulties made the evaluation difficult in the third and fourth cases and repeat angiography was declined by these two patients. In Cases 2 and 3 preoperative venous angiography had demonstrated that venous obstruction was present despite demonstrable collaterals. In Case 4, apart from external pressure, the cause of obstruction was intraluminal blood clots and tumor pieces. Therefore, in conclusion, it seems unlikely that, in all cases but the first, deep x-ray therapy alone would have been successful to palliate the venous obstruction. Recurrence of features of superior vena caval obstruction was common after deep x-ray therapy in Le Roux's series. Various sites have been suggested for distal anastomosis, e.g., superior vena cava, azygos vein, right atrial appendage, inferior vena cava, and femoral vein. The use of the right atrial appendage for this purpose was first suggested by McIntyre and Sykes'? and later successfully adopted by others;" 6. 7. 14-16. 20 with gratifying results. We have found the right atrial appendage for distal anastomosis very convenient, easily accessible, and easy for clamping; above all, a good diameter is available. Although we have had experience with only a small number of cases, we have been
Obstruction of superior vena cava
247
encouraged by this method of palliation for relief of inoperable malignant superior vena caval obstruction, with no hospital death or morbidity, and we recommend it in suitable cases. We are grateful to Miss Linda Clark for typing this manuscript. REFERENCES Allansmith, R.: Surgical Treatment of Superior Vena Cava Obstruction Due to Malignant Tumor, J. THORAC. CARDIOVASC. SURG. 44: 258, 1962. 2 Anderson, A. H., Hansen, A. T., Husefeldt, E., Pedersen, A., and Thompson, G. P.: Superior Vena Cava Syndrome-Three Cases Presumably Due to Thrombosis. One Case Treated by Anastomosing the Azygos Vein to the Right Auricle, Acta Med. Scand. 150: 81, 1954.
3 Boruchow,I. B., Bartley, T. D. , Elliott, L. P., and Shiebler, G. L.: Late Superior Vena Cava Syndrome After Superior Vena Cava-Right Pulmonary Artery Anastomosis: Report of Four Cases, N. Engl. J. Med. 281: 646, 1969.
4 Boruchow, I. B., and Johnson, J.: Obstruction of the Vena Cava: Collective Review, Surg. Gynecol. Obstet. 134: 115, 1972.
5 Effler, D. B., and Groves, L. K.: Superior Vena Caval Obstruction, 1. THORAc. CARDIOVASC. SURG. 43: 574, 1962.
6 Effeney, D. J., Winson, H. M., and Shanahan, M. X.: Superior Vena Caval Obstruction: Resection and Bypass for Malignant Lesions, Aust. N. Z. J. Surg. 42: 231, 1973.
7 Ellis, P. R., Del Rasario, C. V.: Internal Mammary Artery to Superior Vena Cava Fistula: An Adjunct to Superior Vena Cava Replacement, Ann. Thorac. Surg. 4: 74, 1967.
8 Jensen, N. K., Garamella, J. J., Schmidt, W. R., Hoffman, G. L., and Scharf, G.: Vena Caval Replacement in Man by TeflonGraft: A Case Report, J. THORAc. CARDIOVASC. SURG. 44: 56, 1962. 9 Le Roux, B. T.: Bronchial Carcinoma., Edinburg, 1968, E. & S. Livingstone, Ltd., pp. 104-107. 10 Mcintyre, F. T., and Sykes, E. M.: Obstruction of Superior Vena Cava: Review of Literature and Report of Two Personal Cases, Ann. Intern. Med. 30: 925, 1949. II Salsali, M., and Clifton, E. E.: Superior Vena Caval Obstruction With Carcinoma of Lung, Surg. Gynecol. Obstet. 121: 783, 1965. 12 Salsali, M.: A Safe Technique for Resection of Nonobstructed Superior Vena Cava, Surg. Gynecol. Obstet. 123: 91, 1966. 13 Salsali, M., and Clifton, E. E.: Superior Vena Caval Obstruction in Carcinoma of lung, N. Y. State J. Med. 69: 2875, 1969. 14 Schramel, R., and Olinde, H. D.: A New Method of
The Journal of
248 Avasthi and Moghissi
Thoracic and Cardiovascular Surgery
15
16
17
18
Bypassing the Obstructed Vena Cava, J. THORAc. CARDIOVASC. SURG. 41: 375, 1961. Shaw, K. M.: Prosthetic Replacement of the Superior Vena Cava: A Report of Two Cases, J. Irish Med. Assoc. 59: 123, 1966. Skinner, D. B., Saltzman, E. W., and Scannell, J. C.: The Challenge of Superior Vena Caval Obstruction, J. THoRAc. CARDIOVASe. SURG. 49: 824, 1965. Straub, W.H.,Fayos,J. V., and Lampe, I.: The Role of Radiation in Treatment of Superior Vena Cava Syndrome, Univ. Mich. Med. Cent. 1. 35: 158, 1969. Taylor, G. A., Miller, H. A., Standen, J. R., and Harrison, A. W.: Bypassing the Obstructed Superior Vena Cava With a Subcutaneous Long Saphenous Vein Graft, J. THoRAe. CARDIOVASe. SURG. 68: 237, 1974.
19 Tama, L., Ellis, F. H., Jr., Hodgson, C. H., and Dockerty, M. B.: Chemodectoma of the Mediastinum: Report on a Patient With Superior Vena Caval Obstruction Treated by a Shunt From the Right Innominate Vein to the Right Atrium, 1. THoRAe. CARDIOVASC. SURG. 43: 585, 1962. 20 Urschel, H. C,; and Paulson, D. L.: Superior Vena Caval Obstruction, Dis. Chest 49: 155, 1966. 21 Lowe, L. G., and Bush, I. M.: Resection of Vena Cava for Renal Cell Carcinoma. An Experimental Study, J. Uro!' 107: 717, 1972. 22 Szur, L., and Bromley, L. C.: Obstruction of the Superior Vena Cava in Carcinoma of the Bronchus, Br. Med. J. 2: 1273, 1956.
Ram Bandhu Avasthi, M.B., B.S., F.R.C.S. (Eng. and Edin.), and Keyvan Moghissi, F.R.C.S., Cottingham, England
T
he commonest cause of obstruction of the superior vena cava is malignancy. Usually the treatment is difficult and results are disappointing. In our department four such cases were treated by palliative surgery and they are discussed here.
Case reports CASE I. K. C., a 51-year-old housewife, was first seen on Dec. 17, 1974, having had signs and symptoms of superior vena caval obstruction for 3 weeks. She smoked 10 to 15 cigarettes a day. Results of routine laboratory investigations were normal. A chest roentgenogram (Fig. I, left) showed an opacity in the right upper zone compatible with enlarged paratracheal glands. Results of bronchoscopy and right scalene fat biopsy were normal. Venous angiography (Fig. 1, center) showed almost total occlusion of the superior vena cava. On Dec. 31, 1974, a median sternotomy was performed with a view to resection and grafting of the superior vena cava. There was a hard mass along the whole length of the superior vena cava, causing its obstruction and invading the trachea, paratracheal glands, the hilum of the right lung, and its main pulmonary artery. Finger exploration through the
From the Department of Cardiovascular and Thoracic Surgery, Castle Hill Hospital, Cottingham, N. Humberside, England. Received for publication Dec. 29, 1976. Accepted for publication March II, 1977. Address for reprints: Mr. Ram Bandhu Avasthi, Thoracic Surgical Unit, City Hospital, Greenbank Drive, Edinburgh EHIO 5SB, U. K.
244
right atrial appendage confirmed almost total obstruction of the superior vena cava. Biopsy of this mass revealed anaplastic small cell bronchial carcinoma. The tumor was obviously unresectable. A 10 mm. diameter Dacron graft was inserted obliquely, end-to-side, between the left innominate vein and the right atrial appendage. This procedure dropped the central venous pressure from 35 to 12 ern. H 20 immediately after placement of the bypass graft. Recovery was uneventful. Within 24 hours the symptoms and signs of superior vena caval obstruction had abated, and the prominent chest wall veins were invisible after 2 days. Warfarin was given for anticoagulation. At 17 days, a venous angiogram confirmed the graft's patency. At 5 weeks deep x-ray therapy was commenced. At 15 weeks the patient was asymptomatic, there was no evidence of venous obstruction, and the chest x-ray film was normal (Fig. 1, right). She had been well for 12 months when metastases appeared, and she died at home 14 months postoperatively. Permission for autopsy was refused. At no time was venous obstruction present after the operation. CASE 2. F. W. P., a 58-year-old male security officer, was first seen on Jan. 22, 1976, with cough, dyspnea, poor appetite, signs and symptoms of superior vena caval obstruction, and stridor. A chest roentgenogram (Fig. 2, left) showed an opacity in the right upper zone and right hilum and a raised diaphragm. Bronchoscopy revealed obstruction of the right main bronchus owing to squamous cell carcinoma. Venous angiography showed (Fig. 2, center) obstruction of the superior vena cava and collaterals, via azygos and hemiazygos systems, to the inferior vena cava. On Feb. 2, 1976, a median sternotomy was carried out. A large tumor in the superior mediastinum, involving major structures around
Volume 74 Number 2
August.19n
Obstruction of superior vena cava
245
Fig. 1. Case I: Left, Preoperative chest roentgenogram. Center, Roentgenogram of superior vena cava. Right, Postoperative chest roentgenogram .
Fig. 2. Case 2: Left. Preoperative chest roentgenogram. Center, Roentgenogram of superior vena cava. Right, Postoperative chest roentgenogram .
it, was assessed unresectable. A 10 mm. Dacron graft was inserted end-to-side between the left innominate vein and the right atrial appendage. Recovery was uneventful, and within 24 hours the signs of superior vena caval obstruction had started to improve. The patient was given warfarin and a diuretic. Two weeks later deep x-ray therapy was commenced. At 7 weeks a venous angiogram showed partial obstruction of the graft with only a narrow channel through it. Eight months later the patient was doing well and had no signs of venous obstruction (Fig . 2, right). C ASE 3. H. S., a 61-year-old male welder, was first seen on March 29, 1976, having had signs and symptoms of superior vena caval obstruction, along with dyspnea , tightness in the chest, and weight loss, for 2 months. He had finger clubbing. A chest roentgenogram (Fig. 3, left) showed a wide mediastinum. Bronchoscopy showed a broad carina , narrow right upper lobe orifice, but no intrabronchial tumor. Venous angiography (Fig. 3, center ) showed displacement and infiltration of both innominate veins and almost complete obstruction of the superior vena cava . Collaterals via azygos
and hemiazygos systems were present. On May 16, 1976, a median sternotomy was performed. A tumor in the superior mediastinum, involving the superior vena cava, right bronchus, thymus, and distal parts of both innominate veins, on histology proved to be a moderately well-differentiated squamous cell carcinoma of bronchial origin. A 10 mm. endto-end Dacron graft was placed between the left innominate vein and the right atrial appendage . The signs of superior vena caval obstruction disappeared in a week. Recovery was satisfactory . The patient was given warfarin and a diuretic. Deep x-ray therapy was commenced at 2 weeks , and at 5 weeks he was discharged home , fit and well (Fig . 3, right). He was readmitted 3 months later with dysphagia owing to external compression of the esophagus ; this improved with esophageal dilatation. At 5 months he was readmitted with metastases and died in the hospital a month later. Postoperative venography was unsatisfactory for technical reasons . Permission for autopsy was refused . CASE 4 . G . E., a 61-year-old housewife, was seen on July 7, 1976, having had cough, sputum , dyspnea , and signs and
The Journal of
246 Avasthi and Moghissi
Thoracic and Cardiovascular Surgery
Fig. 3. Case 3: Left, Preoperative chest roentgenogram. Center. Roentgenogram of superior vena cava. Right. Postoperative chest roentgenogram.
Fig. 4. Case 4: Left. Preoperative chest roentgenogram. Center, Roentgenogram of superior vena cava. Right. Postoperative chest roentgenogram. symptoms of superior vena caval obstruction for 3 weeks. She had been a heavy smoker for many years. A chest roentgenogram showed a right hilar opacity (Fig. 4, left). Bronchoscopy revealed a narrowed right upper lobe orifice, and a blind biopsy was negative for malignancy. Venous angiography (Fig. 4, center) showed complete obstruction of the superior vena cava just above the right atrium. On July 14, 1976, a median sternotomy was performed. A large tumor in the right side of the superior mediastinum, involving the right main bronchus, the origin of the main pulmonary artery, and the thymus, histologically proved to be a large cell anaplastic bronchial carcinoma, assessed as inoperable. Exploration of the left innominate vein showed this to be filled with fragments of tumor tissue and blood clots, which were removed with ease. A 10 mm. Dacron graft was inserted end-to-side between the left innominate vein and the right atrial appendage. Recovery was uneventful and there was a dramatic relief of superior vena caval obstruction. The patient
was given warfarin and a diuretic. Two weeks later, deep x-ray therapy was started. Ten weeks later she was doing well and fully active (Fig. 4, right).
Discussion The incidence of bronchogenic carcinoma is increasing progressively, 12-14 and 75 to 90 percent of the cases of obstructed superior vena cava are due to this condition, a fact supported by many. 3-5, 16. 18 The Brompton Hospitalf reported that 14 percent of patients with bronchial carcinoma develop superior vena caval obstruction; this figure was 4.6 percent in a review of 4,000 cases by Le Roux.? Clamping of the superior vena cava for resection and replacement can have a high mortality rate, but its partial excision has been
Volume74 Number 2 August, 1977
carried out by Lowe and Bush.>' On the other hand, to have a good bypass for superior vena caval obstruction, certain graft properties should be considered, e.g., nonthrombogenic surface, lumen rigidity to resist external pressure, good sutureline to prevent stricture at the anastomotic site, graft lumen larger than the host vessel diameter, and good flow rate and pressure to keep the graft patent. It is difficult to achieve all these requisites, and therefore thrombosis of the graft, immediately and later postoperatively, is not uncommon. Most workers usually use deep x-ray therapy for palliation of this eondition'{- 13. 16. 17. 20 and many others. Some have used synthetic grafts to bypass this condition!- 6. 8. 19 with supportive results. In our group all four patients had severe signs and symptoms of superior vena caval obstruction, necessitating some form of treatment. We chose surgical bypass for palliation for prompt relief. The improvement was significantly remarkable and quick in cases 1 and 4. None of the patients had recurrence of venous obstruction at any stage following the operation. The first patient was fit and well for 12 months and died at 14 months. The third was well for 3 months, then had dysphagia, which was improved by simple dilatation, and died at 6 months with metastases. Patients 2 and 4 are doing well. Graft patency was satisfactory in the first case and partial in the second; technical difficulties made the evaluation difficult in the third and fourth cases and repeat angiography was declined by these two patients. In Cases 2 and 3 preoperative venous angiography had demonstrated that venous obstruction was present despite demonstrable collaterals. In Case 4, apart from external pressure, the cause of obstruction was intraluminal blood clots and tumor pieces. Therefore, in conclusion, it seems unlikely that, in all cases but the first, deep x-ray therapy alone would have been successful to palliate the venous obstruction. Recurrence of features of superior vena caval obstruction was common after deep x-ray therapy in Le Roux's series. Various sites have been suggested for distal anastomosis, e.g., superior vena cava, azygos vein, right atrial appendage, inferior vena cava, and femoral vein. The use of the right atrial appendage for this purpose was first suggested by McIntyre and Sykes'? and later successfully adopted by others;" 6. 7. 14-16. 20 with gratifying results. We have found the right atrial appendage for distal anastomosis very convenient, easily accessible, and easy for clamping; above all, a good diameter is available. Although we have had experience with only a small number of cases, we have been
Obstruction of superior vena cava
247
encouraged by this method of palliation for relief of inoperable malignant superior vena caval obstruction, with no hospital death or morbidity, and we recommend it in suitable cases. We are grateful to Miss Linda Clark for typing this manuscript. REFERENCES Allansmith, R.: Surgical Treatment of Superior Vena Cava Obstruction Due to Malignant Tumor, J. THORAC. CARDIOVASC. SURG. 44: 258, 1962. 2 Anderson, A. H., Hansen, A. T., Husefeldt, E., Pedersen, A., and Thompson, G. P.: Superior Vena Cava Syndrome-Three Cases Presumably Due to Thrombosis. One Case Treated by Anastomosing the Azygos Vein to the Right Auricle, Acta Med. Scand. 150: 81, 1954.
3 Boruchow,I. B., Bartley, T. D. , Elliott, L. P., and Shiebler, G. L.: Late Superior Vena Cava Syndrome After Superior Vena Cava-Right Pulmonary Artery Anastomosis: Report of Four Cases, N. Engl. J. Med. 281: 646, 1969.
4 Boruchow, I. B., and Johnson, J.: Obstruction of the Vena Cava: Collective Review, Surg. Gynecol. Obstet. 134: 115, 1972.
5 Effler, D. B., and Groves, L. K.: Superior Vena Caval Obstruction, 1. THORAc. CARDIOVASC. SURG. 43: 574, 1962.
6 Effeney, D. J., Winson, H. M., and Shanahan, M. X.: Superior Vena Caval Obstruction: Resection and Bypass for Malignant Lesions, Aust. N. Z. J. Surg. 42: 231, 1973.
7 Ellis, P. R., Del Rasario, C. V.: Internal Mammary Artery to Superior Vena Cava Fistula: An Adjunct to Superior Vena Cava Replacement, Ann. Thorac. Surg. 4: 74, 1967.
8 Jensen, N. K., Garamella, J. J., Schmidt, W. R., Hoffman, G. L., and Scharf, G.: Vena Caval Replacement in Man by TeflonGraft: A Case Report, J. THORAc. CARDIOVASC. SURG. 44: 56, 1962. 9 Le Roux, B. T.: Bronchial Carcinoma., Edinburg, 1968, E. & S. Livingstone, Ltd., pp. 104-107. 10 Mcintyre, F. T., and Sykes, E. M.: Obstruction of Superior Vena Cava: Review of Literature and Report of Two Personal Cases, Ann. Intern. Med. 30: 925, 1949. II Salsali, M., and Clifton, E. E.: Superior Vena Caval Obstruction With Carcinoma of Lung, Surg. Gynecol. Obstet. 121: 783, 1965. 12 Salsali, M.: A Safe Technique for Resection of Nonobstructed Superior Vena Cava, Surg. Gynecol. Obstet. 123: 91, 1966. 13 Salsali, M., and Clifton, E. E.: Superior Vena Caval Obstruction in Carcinoma of lung, N. Y. State J. Med. 69: 2875, 1969. 14 Schramel, R., and Olinde, H. D.: A New Method of
The Journal of
248 Avasthi and Moghissi
Thoracic and Cardiovascular Surgery
15
16
17
18
Bypassing the Obstructed Vena Cava, J. THORAc. CARDIOVASC. SURG. 41: 375, 1961. Shaw, K. M.: Prosthetic Replacement of the Superior Vena Cava: A Report of Two Cases, J. Irish Med. Assoc. 59: 123, 1966. Skinner, D. B., Saltzman, E. W., and Scannell, J. C.: The Challenge of Superior Vena Caval Obstruction, J. THoRAc. CARDIOVASe. SURG. 49: 824, 1965. Straub, W.H.,Fayos,J. V., and Lampe, I.: The Role of Radiation in Treatment of Superior Vena Cava Syndrome, Univ. Mich. Med. Cent. 1. 35: 158, 1969. Taylor, G. A., Miller, H. A., Standen, J. R., and Harrison, A. W.: Bypassing the Obstructed Superior Vena Cava With a Subcutaneous Long Saphenous Vein Graft, J. THoRAe. CARDIOVASe. SURG. 68: 237, 1974.
19 Tama, L., Ellis, F. H., Jr., Hodgson, C. H., and Dockerty, M. B.: Chemodectoma of the Mediastinum: Report on a Patient With Superior Vena Caval Obstruction Treated by a Shunt From the Right Innominate Vein to the Right Atrium, 1. THoRAe. CARDIOVASC. SURG. 43: 585, 1962. 20 Urschel, H. C,; and Paulson, D. L.: Superior Vena Caval Obstruction, Dis. Chest 49: 155, 1966. 21 Lowe, L. G., and Bush, I. M.: Resection of Vena Cava for Renal Cell Carcinoma. An Experimental Study, J. Uro!' 107: 717, 1972. 22 Szur, L., and Bromley, L. C.: Obstruction of the Superior Vena Cava in Carcinoma of the Bronchus, Br. Med. J. 2: 1273, 1956.