Results of Superior Vena Cava Reconstruction With Externally Supported Polytetrafluorethylene Vascular Prostheses

Abstract

Conclusion: Superior vena cava (SVC) reconstructions with externally supported polytetrafluorethylene (PTFE) grafts have low perioperative mortality and high short-term patency. Summary: SVC obstruction can result in facial swelling, dyspnea, and stridor. The SVC, depending on individual circumstances, may be reconstructed with autogenous tissue, stents, or grafts. In this report, the authors describe experience with SVC reconstruction using externally supported PTFE grafts. The study spans 1991 to 2002 and was a retrospective review of medical records of 38 patients with SVC reconstruction with externally supported PTFE grafts. All but four patients had reconstruction for malignant disease. Mean age was 45 ± 15.8 years, and 77% were men. The surgical approach was sternotomy in 27 and thoracotomy in 8, with a clamshell incision in 3 and a trap-door incision in 1. The technique involved initial dissection of the tumor or benign surrounding tissue with assessment of the SVC. The innominate veins and the SVC just proximal to right atrial–SVC junction were both isolated. The azygous vein was ligated. SVC clamping was well tolerated hemodynamically. Hemodynamic compromise was easily stabilized with fluid administration or vasopressor medications. Two patients with tumors extending to the right atrium required cardiopulmonary bypass. The most common graft size diameter was 16 mm (range, 8-19 mm). A right innominate vein to SVC graft was done in 18 patients (47%), a left innominate vein to SVC interposition graft in 8 (21%), grafts from the proximal to distal SVC in 9 (24%), and the remaining 3 patients underwent Y-type reconstructions. Graft diameters ranged from 8 to 16 mm when an isolated innominate vein SVC reconstruction was preformed and from 13 to 19 mm when the graft went from the proximal SVC to the distal SVC. Follow-up averaged 15 months (range, 1-113 months), during which 11 patients (29%) died. At the last follow-up, all patients demonstrated minimal to no brachiocephalic swelling. Imaging was performed after an average of 24 months (range, 1-113 months) in 20 patients (53%). Postoperative anticoagulation consisted of aspirin only in all but 2 patients. In patients undergoing imaging, only 2 of the 20 demonstrated graft occlusion. Comment: This series of SVC reconstructions primarily for malignant disease has technical points worth noting. Warfarin anticoagulation is apparently not required. Graft occlusion is well tolerated. The authors detail methods to avoid graft kinking, particularly with sternotomy closure. Also, reconstruction of only one innominate vein when SVC innominate confluence is involved provides adequate results. It is technically more difficult to perform a right innominate vein-to-graft anastomosis then a left innominate vein anastomosis. However, the right anastomosis results in minimal graft angulation and direct blood flow into the right atrium. Sternal retractors should be partially closed before creating the second anastomosis in a left innominate to SVC reconstruction. Performing both anastomoses with sternal distraction results in graft kinking with sternotomy closure.