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

Letter to the Editor

Reply to the Editor

Francesco Leo, MD, PhDa, Lorenzo Spaggiari, MD, PhDa,b

a European Institute of Oncology, Thoracic Surgery Department, Milan, Italy
b School of Medicine, University of Milan, Milan, Italy

We thank Drs Rossella and Nazari for their technical comments on the possibility of reconstructing the superior vena cava (SVC) without the need of crossclamping by connecting one brachiocephalic vein (BCV) to the right atrial appendage. It represents an interesting alternative by avoiding temporary SVC occlusion, but we still prefer SVC crossclamping for 3 reasons.

First, in our experience, SVC reconstruction with the BCV stump is at higher risk of thrombosis. We recently reported our experience with 70 cases of SVC resection from 1998 through 2004.1Go Of the 25 complete prosthetic replacements, 6 thromboses were recorded, and 4 of them (66%) were in patients with BCV reconstruction. Possible explanations are the length of the prosthesis, the limited diameter of the BCV, and the discrepancy between SVC and BCV calibers. At present, our indication for BCV reconstruction is limited to situations in which an alternative is not feasible.

Second, hemodynamic instability occurring at SVC crossclamping is a limited problem as long as anesthetists are aware of methods to overcome it.2Go It is a frequent event (30%) that can be managed in almost all cases with aggressive resuscitation maneuvers. Intraoperative hypotension by itself should not stop the operation unless corrective maneuvers are unsuccessful (5% of cases). On the other hand, in our experience right atrial appendage clamping can also cause intraoperative patient instability through the occurrence of supraventricular arrhythmias.

Third, our preference for an SVC prosthesis is the use of bovine pericardium,3Go which is a reliable material, even in the context of pulmonary artery reconstruction.4Go In case of sternotomy or a transmanubrial approach, such a prosthesis on the left BCV might become occluded by manubrial compression at sternal closure. When a left BCV reconstruction is required, we prefer a ringed polytetrafluoroethylene prosthesis.

References

  1. Spaggiari L, Leo F, Veronesi G, Solli P, Galetta D, Tatani B, et al. Superior vena cava resection for lung and mediastinal malignancies: a single-center experience with 70 cases. Ann Thorac Surg 2007;83:223-230.[Abstract/Free Full Text]
  2. Leo F, Della Grazia L, Tullii M, Gasparri R, Borri A, Venturino M, et al. Hemodynamic instability during superior vena cava cross-clamping: predictors, management and clinical consequences. J Thorac Cardiovasc Surg 2007;133:1105-1106.[Free Full Text]
  3. Spaggiari L, Veronesi G, D’Aiuto M, Tosoni A. Superior vena cava reconstruction using heterologous pericardial tube after extended resection for lung cancer. Eur J Cardiothorac Surg 2004;26:649-651.[Abstract/Free Full Text]
  4. Galetta D, Veronesi G, Leo F, Spaggiari L. Pulmonary artery reconstruction by a custom-made heterologous pericardial conduit in the treatment of lung cancer. Lung Cancer 2006;53:241-243.[Medline]

Related Article

Superior vena cava resection without blood flow interruption
Claudio Rossella and Stefano Nazari
J. Thorac. Cardiovasc. Surg. 2007 134: 1097-1098. [Extract] [Full Text] [PDF]




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