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Superior vena caval reconstruction using autologous pericardium
Superior Vena Caval Reconstruction Using Autologous Pericardium William Piccione, Jr, MD, L. Penfield Faber, MD, and William H. Warren, MD Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St Luke's Medical Center, Chicago, Illinois
Tumor involvement of the superior vena cava can occur either by direct extension of the primary tumor or by invasion of superior mediastinal lymph nodes. Removal of a portion of the caval wall may be required to allow adequate margins of resection. The technique described involves placement of an intraluminal shunt and resection of the involved caval wall with reconstruction using autologous pericardium. (Ann Thoruc S l u g 2990;50:427-9)
B
ronchogenic carcinoma can involve the superior vena cava either by direct extension of the primary tumor or by invasion of superior mediastinal lymph nodes. A complete and margin-free resection may require removal of a portion of the wall of the superior vena cava or innominate vein. Reports have described bypassing or replacing an obstructed superior vena cava secondary to tumor involvement with a variety of materials, including Dacron (C.R. Bard, Billerica, MA), Gore-Tex (W.L. Gore, Elkton, MD), saphenous vein, and pericardium [l-41. When an obstructed superior vena cava is bypassed, the construction of a temporary shunt is usually not required as adequate collateral pathways have already developed. In contrast, clamping and reconstruction of a nonobstructed superior vena cava can result in hemodynamic compromise intraoperatively owing to an abrupt decrease in venous return to the heart during clamping. A sudden increase in intracranial venous pressure may also cause irreversible brain damage, and the possibility of an intracranial bleeding episode exists [5, 61. For these reasons, we have always shunted blood from the innominate vein to the right atrium during resection of a nonobstructed superior vena cava. This technique involves placing a tube through the right atrium into the right innominate vein, and, in our experience, has been simple to perform and successful.
Operative Technique If the tumor of the lung is large and bulky and there is direct extension into the wall of the vena cava, the technique of vena caval shunting and resection of a portion of its wall can be more easily accomplished if the lung has been removed. In this instance, it may be Accepted for publication April 4, 1990 Address reprint requests to Dr Piccione, 1725 W Harrison, Suite 850, Chicago, IL 60612.
0 1990 by The Society of Thoracic Surgeons
necessary to cut through the tumor just distal to the involvement of the wall of the vena cava. Seeding of the operating field by tumor cells is speculative, but the added exposure for shunting, resection, and reconstruction has been of benefit. This is not required when lymph nodes invade the wall of the vena cava as an en-bloc resection can be performed. The pericardium is opened as close to the hilum as possible in an attempt to avoid prosthetic patch repair of a large pericardial defect, but the opening must be generous enough to provide adequate exposure of the atrium and proximal cava. If the phrenic nerve has not been involved by the tumor, it can be dissected free and retracted medially. A careful and complete dissection is required to expose adequate lengths of both the right and left innominate veins. Umbilical tapes are then placed around the cava at the atriocaval junction and around each individual innominate vein. The tourniquet at the atriocaval junction should be positioned slightly above the actual junction, if the tumor margin permits, to avoid potential injury to the sinoatrial node. We have not experienced any rhythm disturbances with this technique. The azygos vein is routinely ligated if it has not previously been thrombosed by tumor. A 20F thoracostomy tube is then prepared to serve as the shunt. The distal end of the tube must be cut off so that only two or three sideholes of the chest tube remain and are distal to the occluding tourniquet at the innominate level. The tube is then measured against the length of the superior vena cava and right atrium, and a single hole is cut into the side wall of the tube at an appropriate distance that will permit the side hole to direct the flow of shunted blood into the right atrium and still be distal to the occluding atriocaval tourniquet. The patient is then anticoagulated with 5,000 U of sodium heparin given intravenously. A pursestring suture is placed in the wall of the right atrium just as if one were preparing the placement of a venous drainage catheter for cardiopulmonary bypass. A stab wound is made into the atrium wall in the center of the pursestring suture, and the shunt is inserted into the right atrium and through the vena cava into the right innominate vein. The distal end of the shunt is occluded with a clamp. Securing the tourniquets with careful positioning of the shunt will effectively isolate the involved portion of the superior vena cava while maintaining venous return to the heart (Fig 1A). The involved caval wall can then be completely resected with histological examination of the margin by frozen-section analysis. We have usually been able to 0003-4975/90/$3.50
418
Ann Thorac Surg
PICCIONE ET AL SUPERIOR VENA CAVAL RECONSTRUCTION
1990;50:417-9
D
L
B
Fig 1. (A) Shunt properly positioned in the superior vena cava by right atrial pursestring. ( B ) Tourniquets snared to allow isolation and excision of involved caval wall. ( C ) Pericardial flap sutured into place. Suture line should begin on the most posterior and medial aspect of the caval wall. (D)Completed reconstruction with shunt removed and p o w reestablished.
retain a segment of the medial vena cava in our resections (Fig 1B). We do not routinely use a central venous pressure catheter as it would lie in the area of caval resection;
however, the anesthesiologist is alerted to watch the face and neck veins carefully for engorgement while the shunt is in place. The flow through a 20F catheter has been adequate in our experience to date.
PICCIONE ET AL SUPERIOR VENA CAVAL RECONSTRUCTION
Ann Thorac Surg 1990;50417-9
419
Table 1. Summay of Patients Undergoing Concomitant Superior Vena Caval Reconstruction and Pulmonay Resection" Sex
Age
(Y)
M
60
M
40
F
42
F
73
M
52
M
61
a
svc
Operation
Specimen
Follow-up
~_______
Right pneumonectomy, squamous cell CA Right upper lobectomy, neuroendocrine CA Right pneumonectomy, squamous cell CA Right pneumonectomy, squamous cell CA
Positive
Right sleeve pneumonectomy, squamous cell CA Right pneumonectomy, neuroendocrine CA
Margins of resection at operation were free of tumor in all patients. NED = no evidence of recurrent disease; DOD = dead of disease;
CA = carcinoma;
A piece of pericardium large enough for reconstruction of the caval defect is then obtained. The pericardium is sutured into the caval defect with a running 4-0 Prolene suture (Ethicon, Somerville, NJ) beginning posteriorly and medially (Fig 1C). The pericardium is oriented with the visceral surface toward the caval lumen. The sutures should be closely spaced, and the patch is always made patulous to avoid any possibility of lumen compromise. Once the procedure is completed, the innominate tourniquets are released to aid in removal of air before removal of the shunt (Fig 1D). It is always necessary to evaluate carefully the size of the resulting pericardial defect to judge whether cardiac herniation may occur. It may be necessary to place a prosthetic patch to avoid this complication, particularly if a right pneumonectomy has been accomplished.
Comment We used this technique of superior vena caval shunting, resection, and reconstruction in 6 patients with caval wall involvement with tumor and achieved satisfactory results (Table 1). One patient died in the early postoperative period of a ventricular arrhythmia; postmortem examination showed a patent superior vena caval reconstruction without evidence of stenosis or thrombus. A second patient died of recurrent disease at 11 months, and again postmortem examination showed a patent reconstructed vena cava. The remaining patients have not had clinical evidence of caval obstruction or any complications related to this technique. Assessment of patency has been made only by clinical examination to date. We do not believe that use of more invasive methods of assessment are justified in this population of patients with advanced disease.
Positive
DOD at 11 mo, SVC patent at autopsy NED at 42 mo
Positive
DOD at 4 mo
Positive Positive
Dead of arrhythmia at 17 days, SVC patent at autopsy NED at 14 mo
Positive
NED at 4 mo
SVC = superior vena cava.
We favor the use of pericardium over prosthetic materials such as Gore-Tex or Dacron primarily because of the potential of thrombogenicity. Spiral saphenous vein grafts potentially could be used for this application but we find them to be more time consuming without any obvious advantage. This technique has not been used in superior vena cavas that are totally obstructed by tumor, and we do not advocate the described technique for that application. However, this technique can be of benefit when resection of a large portion of the superior vena cava is necessary to achieve a complete resection. Experience to date is still too limited to assess accurately any impact on patient survival using this technique with concomitant pulmonary resection for bronchogenic carcinoma.
References 1. Avasthi RB, Moghissi K. Malignant obstruction of the superior vena cava and its palliation. J Thorac Cardiovasc Surg 1977; 74244-8. 2. Fiore AC, Brown JW, Cromartie RS, et al. Prosthetic replacement for the thoracic vena cava. J Thorac Cardiovasc Surg 1982;84:56&7. 3. Doty DB. Bypass of superior vena cava. J Thorac Cardiovasc Surg 1982;83:326-37. 4. Zembala M, Kustrzycki A, Ostapczuk S, Dutkiewicz R, Hirnle T. Pericardial tube for obstruction of superior vena cava by malignant teratome. J Thorac Cardiovasc Surg 1986;91:469-71. 5. Jarvis FJ, Kanar EA. Physiological changes following obstruction of the superior vena cava. J Thorac Surg 1954;27213-21. 6. Salsali M. A safe technique for reconstruction of the nonobstructed superior vena cava. Surg Gynecol Obstet 1966;123: 91-8.
Tumor involvement of the superior vena cava can occur either by direct extension of the primary tumor or by invasion of superior mediastinal lymph nodes. Removal of a portion of the caval wall may be required to allow adequate margins of resection. The technique described involves placement of an intraluminal shunt and resection of the involved caval wall with reconstruction using autologous pericardium. (Ann Thoruc S l u g 2990;50:427-9)
B
ronchogenic carcinoma can involve the superior vena cava either by direct extension of the primary tumor or by invasion of superior mediastinal lymph nodes. A complete and margin-free resection may require removal of a portion of the wall of the superior vena cava or innominate vein. Reports have described bypassing or replacing an obstructed superior vena cava secondary to tumor involvement with a variety of materials, including Dacron (C.R. Bard, Billerica, MA), Gore-Tex (W.L. Gore, Elkton, MD), saphenous vein, and pericardium [l-41. When an obstructed superior vena cava is bypassed, the construction of a temporary shunt is usually not required as adequate collateral pathways have already developed. In contrast, clamping and reconstruction of a nonobstructed superior vena cava can result in hemodynamic compromise intraoperatively owing to an abrupt decrease in venous return to the heart during clamping. A sudden increase in intracranial venous pressure may also cause irreversible brain damage, and the possibility of an intracranial bleeding episode exists [5, 61. For these reasons, we have always shunted blood from the innominate vein to the right atrium during resection of a nonobstructed superior vena cava. This technique involves placing a tube through the right atrium into the right innominate vein, and, in our experience, has been simple to perform and successful.
Operative Technique If the tumor of the lung is large and bulky and there is direct extension into the wall of the vena cava, the technique of vena caval shunting and resection of a portion of its wall can be more easily accomplished if the lung has been removed. In this instance, it may be Accepted for publication April 4, 1990 Address reprint requests to Dr Piccione, 1725 W Harrison, Suite 850, Chicago, IL 60612.
0 1990 by The Society of Thoracic Surgeons
necessary to cut through the tumor just distal to the involvement of the wall of the vena cava. Seeding of the operating field by tumor cells is speculative, but the added exposure for shunting, resection, and reconstruction has been of benefit. This is not required when lymph nodes invade the wall of the vena cava as an en-bloc resection can be performed. The pericardium is opened as close to the hilum as possible in an attempt to avoid prosthetic patch repair of a large pericardial defect, but the opening must be generous enough to provide adequate exposure of the atrium and proximal cava. If the phrenic nerve has not been involved by the tumor, it can be dissected free and retracted medially. A careful and complete dissection is required to expose adequate lengths of both the right and left innominate veins. Umbilical tapes are then placed around the cava at the atriocaval junction and around each individual innominate vein. The tourniquet at the atriocaval junction should be positioned slightly above the actual junction, if the tumor margin permits, to avoid potential injury to the sinoatrial node. We have not experienced any rhythm disturbances with this technique. The azygos vein is routinely ligated if it has not previously been thrombosed by tumor. A 20F thoracostomy tube is then prepared to serve as the shunt. The distal end of the tube must be cut off so that only two or three sideholes of the chest tube remain and are distal to the occluding tourniquet at the innominate level. The tube is then measured against the length of the superior vena cava and right atrium, and a single hole is cut into the side wall of the tube at an appropriate distance that will permit the side hole to direct the flow of shunted blood into the right atrium and still be distal to the occluding atriocaval tourniquet. The patient is then anticoagulated with 5,000 U of sodium heparin given intravenously. A pursestring suture is placed in the wall of the right atrium just as if one were preparing the placement of a venous drainage catheter for cardiopulmonary bypass. A stab wound is made into the atrium wall in the center of the pursestring suture, and the shunt is inserted into the right atrium and through the vena cava into the right innominate vein. The distal end of the shunt is occluded with a clamp. Securing the tourniquets with careful positioning of the shunt will effectively isolate the involved portion of the superior vena cava while maintaining venous return to the heart (Fig 1A). The involved caval wall can then be completely resected with histological examination of the margin by frozen-section analysis. We have usually been able to 0003-4975/90/$3.50
418
Ann Thorac Surg
PICCIONE ET AL SUPERIOR VENA CAVAL RECONSTRUCTION
1990;50:417-9
D
L
B
Fig 1. (A) Shunt properly positioned in the superior vena cava by right atrial pursestring. ( B ) Tourniquets snared to allow isolation and excision of involved caval wall. ( C ) Pericardial flap sutured into place. Suture line should begin on the most posterior and medial aspect of the caval wall. (D)Completed reconstruction with shunt removed and p o w reestablished.
retain a segment of the medial vena cava in our resections (Fig 1B). We do not routinely use a central venous pressure catheter as it would lie in the area of caval resection;
however, the anesthesiologist is alerted to watch the face and neck veins carefully for engorgement while the shunt is in place. The flow through a 20F catheter has been adequate in our experience to date.
PICCIONE ET AL SUPERIOR VENA CAVAL RECONSTRUCTION
Ann Thorac Surg 1990;50417-9
419
Table 1. Summay of Patients Undergoing Concomitant Superior Vena Caval Reconstruction and Pulmonay Resection" Sex
Age
(Y)
M
60
M
40
F
42
F
73
M
52
M
61
a
svc
Operation
Specimen
Follow-up
~_______
Right pneumonectomy, squamous cell CA Right upper lobectomy, neuroendocrine CA Right pneumonectomy, squamous cell CA Right pneumonectomy, squamous cell CA
Positive
Right sleeve pneumonectomy, squamous cell CA Right pneumonectomy, neuroendocrine CA
Margins of resection at operation were free of tumor in all patients. NED = no evidence of recurrent disease; DOD = dead of disease;
CA = carcinoma;
A piece of pericardium large enough for reconstruction of the caval defect is then obtained. The pericardium is sutured into the caval defect with a running 4-0 Prolene suture (Ethicon, Somerville, NJ) beginning posteriorly and medially (Fig 1C). The pericardium is oriented with the visceral surface toward the caval lumen. The sutures should be closely spaced, and the patch is always made patulous to avoid any possibility of lumen compromise. Once the procedure is completed, the innominate tourniquets are released to aid in removal of air before removal of the shunt (Fig 1D). It is always necessary to evaluate carefully the size of the resulting pericardial defect to judge whether cardiac herniation may occur. It may be necessary to place a prosthetic patch to avoid this complication, particularly if a right pneumonectomy has been accomplished.
Comment We used this technique of superior vena caval shunting, resection, and reconstruction in 6 patients with caval wall involvement with tumor and achieved satisfactory results (Table 1). One patient died in the early postoperative period of a ventricular arrhythmia; postmortem examination showed a patent superior vena caval reconstruction without evidence of stenosis or thrombus. A second patient died of recurrent disease at 11 months, and again postmortem examination showed a patent reconstructed vena cava. The remaining patients have not had clinical evidence of caval obstruction or any complications related to this technique. Assessment of patency has been made only by clinical examination to date. We do not believe that use of more invasive methods of assessment are justified in this population of patients with advanced disease.
Positive
DOD at 11 mo, SVC patent at autopsy NED at 42 mo
Positive
DOD at 4 mo
Positive Positive
Dead of arrhythmia at 17 days, SVC patent at autopsy NED at 14 mo
Positive
NED at 4 mo
SVC = superior vena cava.
We favor the use of pericardium over prosthetic materials such as Gore-Tex or Dacron primarily because of the potential of thrombogenicity. Spiral saphenous vein grafts potentially could be used for this application but we find them to be more time consuming without any obvious advantage. This technique has not been used in superior vena cavas that are totally obstructed by tumor, and we do not advocate the described technique for that application. However, this technique can be of benefit when resection of a large portion of the superior vena cava is necessary to achieve a complete resection. Experience to date is still too limited to assess accurately any impact on patient survival using this technique with concomitant pulmonary resection for bronchogenic carcinoma.
References 1. Avasthi RB, Moghissi K. Malignant obstruction of the superior vena cava and its palliation. J Thorac Cardiovasc Surg 1977; 74244-8. 2. Fiore AC, Brown JW, Cromartie RS, et al. Prosthetic replacement for the thoracic vena cava. J Thorac Cardiovasc Surg 1982;84:56&7. 3. Doty DB. Bypass of superior vena cava. J Thorac Cardiovasc Surg 1982;83:326-37. 4. Zembala M, Kustrzycki A, Ostapczuk S, Dutkiewicz R, Hirnle T. Pericardial tube for obstruction of superior vena cava by malignant teratome. J Thorac Cardiovasc Surg 1986;91:469-71. 5. Jarvis FJ, Kanar EA. Physiological changes following obstruction of the superior vena cava. J Thorac Surg 1954;27213-21. 6. Salsali M. A safe technique for reconstruction of the nonobstructed superior vena cava. Surg Gynecol Obstet 1966;123: 91-8.