Discussion

Abstract

Presenter: Dr Jia-Hao Jiang Dr Erino Angelo Rendina (Rome, Italy). Thank you very much for the privilege of discussing this paper, which is very interesting, however, we have a totally different strategy. So, I will do some comments, more comments than questions, I'm afraid. The others should certainly be commended for presenting an unusual strategic approach to SVC reconstruction associated with thymoma, that is first replace the SVC and subsequently resect the tumor, which is the opposite of what we normally do for some reasons. First of all, because the graft is in your way while doing the resection. Second reason is because we did reconstruct the left innominate vein 25 years ago, but then we realized that trimming it to the proper length with the sternum open and spread is very difficult, and sometimes, it coils and bends, and it might cause thrombosis. Another thing that might cause thrombosis is the anastomosis on the auricle on the right atrial appendage which as we all know has a trabecular anatomy and is very uneven. So, this is the reason why our preferred strategy, when possible, for tumors of the thymus abutting on the right side is to close the left innominate vein, clamp the right innominate vein, clamp the superior vena cava into the pericardium, which is never infiltrated. Tumors in that area usually infiltrate the lung, infiltrate the phrenic nerve, but because of the pericardial fold, the origin of the superior vena cava is almost never infiltrated. At least, this is with my personal experience. Speaking about clamping, no shunt is needed. We used to use it many years ago but now with proper cerebral monitoring, we can safely clamp the venus access completely even up to an hour, which is enough time to do anastomosis and resect the tumor, and with no consequences for the patient. So, having said this, we prefer to resect the patient first, reconstruct the access, which is a direct access from the right innominate vein to the superior vena cava. Straightforward, very smooth endocardium in the superior vena cava, easy anastomosis, and the regular access. Having said this, I have one question. Why use PTFE and maintain long-term anticoagulation when you can use biological prosthesis like pericardium, which is what we usually use? Thank you very much. Dr Jia-Hao Jiang (Shanghai, China). Thank you. Can you repeat your question? Dr Rendina. Why use PTFE? Why PTFE and anticoagulation at long-term? We use pericardium, 4 weeks anticoagulation, and then it's over with anticoagulation. Dr Jiang. Okay, thank you. I see. I'm sorry. There's only 1 type of artificial vessel available for SVC reconstruction at our center for many years, so we don't have the artificial vessels made of other materials. I'm sorry. Thank you. Unidentified Speaker. Thank you. Reno, if you happen to reconstruct the left side like he did with biological material, what do you think about the patency of that with or without anticoagulation? Dr Rendina. The thing is that we never reconstruct the left. It's useless. You have swallowing of the left upper limb for some time but then it recovers, so we never reconstruct the left. We have reconstructed the left in the past with awful results. It's almost always invariably thrombosis. It may be because of us. The technique that our colleague showed us is a wonderful technique. I'm not discussing that. It's clean. The video was beautiful. But in my opinion, the strategy could be better. Dr Jiang. Thank you. Unidentified Speaker. Thank you. Beautiful video.