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J Thorac Cardiovasc Surg 2006;132:192-194
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Department of Thoracic Surgery, University of Rome "La Sapienza," "Sant'Andrea" Hospital, Rome
b Department of Thoracic Surgery, University of Rome "La Sapienza," Policlinico "Umberto I," Rome, Italy
Received for publication February 17, 2006; accepted for publication March 15, 2006. * Address for reprints: Erino A. Rendina, MD, Division of Thoracic Surgery, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Roma, Italy. (Email: erinoangelo.rendina{at}tin.it).
Although the feasibility of resection and prosthetic replacement of the superior vena cava (SVC) has been largely proven,
1
the type of vessel reconstruction is still an object of debate and the search for improved technical devices is currently active.
We describe a new technique for the construction of the pericardial tube that we have successfully used in 2 cases of reconstruction of the SVC.
Clinical Summary
Case 1 was a 50-year-old man who presented with a large right pulmonary mass (11 cm in diameter) invading the carina, SVC, pulmonary artery, and superior pulmonary vein. Histologic diagnosis achieved by endobronchial biopsy was mesenchymal proliferation of uncertain behavior. After laser recanalization of the right main bronchus by rigid bronchoscopy, the patient underwent operation. A right-sleeve pneumonectomy associated with resection and prosthetic reconstruction of the SVC was performed. Pathologic examination documented epithelioid leiomyosarcoma. Twenty-nine hilar and mediastinal nodes were removed. Only 3 peribronchial nodes resulted at pathologic analysis.
Case 2 was a 55-year-old woman who presented with an endoluminal tumor of the SVC with complete vascular obstruction for a longitudinal extension of approximately 7 cm, confirming SVC syndrome. The patient underwent radical removal of the tumor by a complete resection and reconstruction of the SVC. A metastatic tumor of an unidentified origin was found at the pathologic examination.
No intraoperative or postoperative major complications occurred. Both patients are well and without evidence of disease 16 months (case 1) and 13 months (case 2) after surgery.
Surgical Technique
The surgical approach was posterolateral thoracotomy in case 1 and muscle sparing lateral thoracotomy in case 2.
After complete isolation and distal and proximal clamping of the SVC, the caval segment infiltrated by the tumor was resected and vascular continuity was restored by interposition of a heterologous pericardial prosthetic tube. Intravenous sodium heparin (0.5 mg/kg) was administered before clamping. We previously described an original technique for the construction of a biologic conduit.
1,2
The bovine pericardial leaflet is trimmed to a rectangular shape of the resected caval segment length, wrapped around a syringe to obtain the appropriate diameter, and sutured longitudinally. In our past experience, the longitudinal closure was performed with a running suture of 5-0 or 6-0 monofilament nonabsorbable material. In the present experience, we tried to optimize this technique by performing the longitudinal suture with a linear reloadable stapler (gastrointestinal anastomosis stapler with 3.8-mm titanium staples). A 5- or 10-mL syringe (depending on the diameter of the resected vessel) was used to calibrate the graft diameter (Figure 1,
A, B).
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Computed tomography images demonstrating a perfectly patent caval graft 12 months after surgery are shown for both cases in Figure 2. Figure 2, B shows the suture line of the mechanical stapler of a perfectly aligned SVC graft.
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Biologic materials have achieved large acceptance in the reconstructive procedures of low-pressure thoracic great vessels after oncologic resection.
1-5
In the past decade we have extensively used autologous or heterologous pericardium for both patch and prosthetic repair of the SVC and pulmonary artery.
1-3
When an SVC replacement is required, bovine pericardium is preferred because the autologous tissue is not sufficient to create a long conduit. The available detoxified bovine pericardial flaps have strongly improved the graft biocompatibility providing heterologous tissue advantages comparable to those of autologous tissue. The pericardial conduit has lower risks of infection and thrombosis if compared with synthetic materials and does not require long-term anticoagulation. Moreover, bovine pericardium shows further favorable features with respect to fresh tissue. It has even and stiffer edges that make it easier to suture the graft to the vascular wall. Furthermore, bovine pericardium exhibits reduced elasticity, which makes it easier to trim the pericardial graft to the appropriate size. The technical devices described in this article (mechanical stapler) enable a quicker and easier procedure for the tube construction and confer a more regular shape to the vascular graft, so its adaptation to the caval stumps is facilitated. The use of a mechanical suture for the longitudinal closure of the graft adds safety and precision to the previously described technique and reduces the surgical time.
References
This article has been cited by other articles:
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  F. Venuta and E. A. Rendina Superior vena cava resection and reconstruction Eur J Cardiothorac Surg, January 18, 2012; (2012) ezr266v1. [Full Text] [PDF]
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A. M. Ciccone, F. Venuta, A. D'Andrilli, C. Andreetti, M. Ibrahim, T. De Giacomo, D. Massullo, and E. A. Rendina Long-term patency of the stapled bovine pericardial conduit for replacement of the superior vena cava Eur J Cardiothorac Surg, December 1, 2011; 40(6): 1487 - 1491. [Abstract] [Full Text] [PDF]
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 Y. Sekine, H. Suzuki, Y. Saitoh, H. Wada, and S. Yoshida Prosthetic Reconstruction of the Superior Vena Cava for Malignant Disease: Surgical Techniques and Outcomes Ann. Thorac. Surg., July 1, 2010; 90(1): 223 - 228. [Abstract] [Full Text] [PDF]
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