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J Thorac Cardiovasc Surg 2007;134:1097-1098
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Superior vena cava resection without blood flow interruption

Claudio Rossella, MDa, Stefano Nazari, MDa,b

a Consultant, Villa Maria Cecilia Hospital, Cotignola, RA, Italy
b Foundation A. Carrel, Pavia, Italy

To the Editor:

We agree with Leo and associates1Go that clamping of the superior vena cava (SVC) can cause severe hemodynamic changes with possible serious clinical consequences, particularly when the SVC blood flow was not already gradually reduced by venous wall pathology, usually neoplastic infiltration. For this reason, at the beginning of our clinical experience with SVC resections, we successfully used a temporary intraluminal shunt.2Go

However, after a few cases, we shifted to the much more simple and accurate technique of performing, as the first procedure after sternotomy (or thoracotomy), ringed polytetrafluoroethylene graft (12–18 mm) interposition between the amputated right atrial appendage tip and the left (occasionally right on thoracotomy cases) brachiocephalic trunk (Figure 1). This procedure does not interrupt blood flow through the SVC (Figure 1, A), and after the blood flow through this conduit is established, SVC clamping (Figure 1, B) and removal (Figure 1, C) can be carried out with neither clamping time limits nor significant hemodynamic changes.


Figure 1
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  		Figure 1. In all phases of the procedure, upper body district venous discharge is maintained through one of the brachiocephalic trunks.

 
We prefer not to reestablish the prosthetic continuity of the right brachiocephalic trunk with the "atrial" SVC stump because the upper body district venous blood sharing between 2 prosthetic conduits might enhance reduced blood velocity in one of them and its possible thrombosis and infection (3/6 cases of double prosthetic conduits SVC reconstruction in our series).

Obviously, in those infrequent cases in which the SVC can still be patch repaired but the lesion is too extended to allow tangential clamping, the polytetrafluoroethylene graft is kept only temporarily3Go and then removed after SVC reconstruction is completed.

Moreover, even in those cases in which it seems appropriate to site the distal anastomosis on the SVC, the clamping time can be reduced to half if the conduit is first anastomosed to the right atrial appendage instead of to the proximal SVC stump.

References

  1. Leo F, Grazia LD, Tullii M, Gasparri R, Borri A, Venturino M, et al. Hemodynamic instability during superior vena cava crossclamping: Predictors, management, and clinical consequences. J Thorac Cardiovasc Surg 2007;133:1105-1106.[Free Full Text]
  2. Nazari S, Moncalvo F, Zonta A, Prati U, Jemos V. Temporary intraluminal bypass for superior vena cava reconstruction after cancer invasion. Thorac Cardiovasc Surg 1988;36:5-9.[Medline]
  3. Suzuki K, Asamura H, Watanabe S, Tsuchiya R. Combined resection of superior vena cava for lung carcinoma: prognostic significance of patterns of superior vena cava invasion. Ann Thorac Surg 2004;78:1184-1189.[Abstract/Free Full Text]

Related Article

Reply to the Editor
Francesco Leo and Lorenzo Spaggiari
J. Thorac. Cardiovasc. Surg. 2007 134: 1098. [Extract] [Full Text] [PDF]



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[Full Text] [PDF]

This Article
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