Internal Jugular to Atrial Bypass with Spiral Vein Graft for Superior Vena Cava Syndrome

Abstract

The patient was a 41-year-old woman with a history of postpartum class New York Heart Association class II cardiomyopathy. She had undergone biventricular implanTable cardiac defibrillator lead extraction. The procedure was complicated by laceration of the superior vena cava, innominate artery, and confluence of the left subclavian artery. Emergent repair with full cardiopulmonary bypass with bovine pericardial patch angioplasty was performed. During the course of 2 years, the patient had developed superior vena cava syndrome. She described worsening symptoms of severe headaches, blurred vision, near syncope with bending over, and a choking sensation despite sleeping at a 45° head-up angle. Additionally, the patient had developed moderate tricuspid valve regurgitation, which required repair. We elected to repair this patient with a spiral vein graft, in addition to tricuspid valve annuloplasty. Bilateral great saphenous veins were harvested and wrapped around a 36F chest tube such that a 9-mm × 12-cm spiral vein graft was created (Fig 1). After repair of the tricuspid valve, the right internal jugular vein was exposed, and the graft was tunneled through the thoracic inlet and inside a 12-mm ringed polytetrafluoroethylene graft to provide external support. The graft was then anastomosed from the right internal jugular vein to the right atrium. The patient did well and was discharged 6 days postoperatively. During follow-up, the patient has done very well (Fig 2). Five months after surgery, a venogram demonstrated a patent graft, with no pressure gradient across the graft.Fig 2Preoperative (Left) and postoperative (Right) three-dimensional computed tomography reconstructions of the patient demonstrating remarkably decreased venous collaterals. (Bottom) A postoperative venogram demonstrating the widely patent jugular–atrial venous bypass.View Large Image Figure ViewerDownload Hi-res image Download (PPT)