Superior Vena Cava Replacement Research Articles

Extracorporeal membrane oxygenation (ECMO) assisted huge mediastinal tumor resection combined with superior vena cava replacement: A case report and literature review.

As to huge solid mediastinal tumor which direct compression or invasion of the superior/inferior vena cava (SVC/IVC), surgical resection remains the main lifesaving treatment. However, it would present formidable anesthetic challenges due to the extremely high risks of cardiorespiratory compromise, drastic hemodynamic fluctuations and death at all perioperative stages. Here, we report a case of huge anterior mediastinal tumor resection combined with SVC replacement under the assistance of venoarterial extracorporeal membrane oxygenation (VA ECMO), and stable hemodynamics were maintained as well as high internal jugular vein pressure being avoided during the operation procedure. He was weaned off ECMO successfully just after surgery and eventually discharged. No signs of postoperatively neurological complications occurred. Therefore, the use of ECMO assistance in huge mediastinal tumor resection combined with SVC replacement is feasible and safe, which may provide the possibility of surgical treatment for such patients and improve outcomes.

Major vascular reconstructions in thoracic oncological surgery.

The replacement of the superior vena cava and thoracic outlet vessels for thoracic malignancies often becomes necessary for radical oncological surgery. The pulmonary artery can be directly infiltrated by the tumor or affected by metastatic hilar lymph nodes. In some cases, it must be resected and reconstructed to achieve oncological radicality and/or avoid pneumonectomy. This study reflects a single-surgeon, retrospective experience spanning 6years (2017-2023). We reviewed data from patients undergoing early anticoagulant therapy after superior vena cava or thoracic outlet vessels bypass and from patients undergoing early antiaggregation therapy following pulmonary artery reconstruction or resection. This series comprises 41 patients treated by a single surgeon. Fourteen patients underwent superior vena cava and thoracic outlet vessel procedures. Among these, eight patients received superior vena cava replacement (six for thymic malignancies and two for lung cancer), and six patients underwent jugular and subclavian artery/vein resection or replacement (all six had sarcomas). There was one death due to respiratory failure, not associated with bleeding or bypass closure. Additionally, there was one graft closure in a patient with severe coagulopathy and three instances of hemothorax (two patients had undiagnosed complex coagulopathies not evident in pre-operative routine blood tests). Following bleeding incidents, anticoagulation was initiated the next day in one case and based on hematological indications in the two coagulopathic patients. In the pulmonary artery series, 27 patients were involved: 20 underwent direct suture after tangential resection, and 7 received pericardial patch reconstruction. Only one case experienced bleeding necessitating redo-surgery. All these patients received early and chronic antiaggregation therapy after pulmonary artery reconstruction. We conclude that major thoracic oncological vascular surgery is safe and feasible with appropriate technical skills. However, achieving optimal results requires integration with correct early anticoagulant therapy or antiaggregation to maintain the patency of bypasses/grafts and prevent life-threatening risks associated with closure of the "new vessels."

Superior vena cava prosthetic replacement for non-small cell lung cancer: is it worthwhile?

Direct involvement of the superior vena cava (SVC) by non-small cell lung cancer (NSCLC) requires en-bloc tumour resection with complete vascular clamping and prosthetic replacement. We report the outcomes of this highly demanding procedure in the largest patient cohort to date. We searched our institution's database for patients who underwent complete en-bloc resection of NSCLC invading the SVC followed by prosthetic SVC replacement, between 1980 and 2018. Patients with cN2, cN3 or distant metastases were not eligible. We identified 48 patients (38 males, 10 females; mean age of 57 years; tumour size, 1.9-17 cm). Neoadjuvant therapy was administered to 17 and adjuvant therapy to 31 patients. R0 resection was achieved in 41 (85%) patients; lymph node involvement was pN0 in 8, pN1 in 23, pN2 in 14 and pN3 in 3 patients. Five patients died within 30 days of surgery. Right pneumonectomy was significantly associated with postoperative death (P = 0.02). Postoperative complications developed in 13 other patients. No neurologic events related to SVC clamping occurred. Graft thrombosis developed in 2 patients. Median survival was 24 months; 3-, 5- and 10-year survival rates were 45%, 40% and 35%, respectively; and corresponding disease-free survival rates were 37%, 37% and 30%, respectively. By univariable analysis, only margin-free (R0) resection was associated with better survival (P = 0.02). In highly selected patients with NSCLC involving the SVC, mortality is acceptable after complete en-bloc resection and prosthetic replacement done in an expert centre. SVC involvement should not preclude consideration of curative resection in selected patients.

Surgical feasibility and long-term outcome of superior vena cava replacement for advanced thymoma in patients undergoing preoperative chemotherapy or chemoradiotherapy.

BackgroundThe aim of this study was to investigate the long‐term outcome of superior vena cava (SVC) replacement after chemotherapy or chemoradiotherapy for advanced thymoma.MethodsThe medical information of patients with advanced thymoma who underwent thymoma resection and SVC replacement in Beijing Tongren Hospital from 2002 to 2017 were reviewed. We compared surgical outcomes, postoperative complications and long‐term prognosis in the chemoradiotherapy + surgery group (CRT + surgery group, 19 cases) and the surgery group (26 cases).ResultsThe operation time (486.05 ± 148.01 vs. 370.77 ± 124.32 min; p = 0.007) and intraoperative blood loss (1400 ml [IQR 1125–2105 ml] vs. 855 ml [IQR 555–1682.5 ml], p = 0.036), poor wound healing (three cases [15.79%] vs. zero cases [0.0%], p = 0.036) in the CRT + surgery group were significantly higher than those of the surgery group. There was no significant difference between the CRT + surgery group and the surgery group in postoperative chest tube drainage time, hospitalization time, postoperative arrhythmia and incidence of pneumonia. Kaplan Meier analysis showed that the recurrence‐free survival (RFS) curves of the CRT + surgery group patients were better than those of the surgery group (p = 0.031). However, overall survival (OS) between the two groups was not significantly different (p = 0.069).ConclusionsThymoma resection and SVC replacement is feasible for patients undergoing preoperative induction chemotherapy or chemoradiotherapy for advanced thymoma. Although patients in the CRT + surgery group had a longer operation time and increased intraoperative bleeding, the RFS rate seemed to be better than that in the surgery group.

Specific airway management for SVC replacement during giant anterior mediastinal tumor resection

BackgroundGiant anterior mediastinal tumor (GAMT) resection is a challenging procedure, for which anesthesiologist might take to need special precautions.Case presentationA 48-year-old male patient had been scheduled to undergo GAMT resection and superior vena cava (SVC) replacement. The tumor spread surrounding SVC and left main bronchus (LMB), resulting in small volume of his left lung. A soft left-sided double lumen tube (DLT) was selected to keep the patency of LMB during left one lung ventilation (OLV) against the tumor weight. Semi-awake intubation with spontaneous breathing was selected for DLT insertion to avoid lower airway occlusion. During left OLV after right open thoracotomy, his SPO2 decreased below to 90%. We performed selective right upper lobe bronchial blockade using the combination of DLT and bronchial blocker. The surgery was successfully completed with this strategy.ConclusionsAlthough such cases are rare, they are informative for anesthesiologists, providing optional strategies.

Thoracic tumor resection combined with SVC replacement using autologous pericardium

BackgroundInvasion of the superior vena cava (SVC) by thoracic tumors and occurrence of SVC syndrome are often encountered in clinical practice; but the prognosis in these cases is poor. Replacement of the SVC with autologous pericardial tissue is rarely performed. In this study, we sought to investigate the postoperative outcomes of this rare procedure.MethodsWe performed a retrospective analysis of six patients who underwent SVC replacement using autologous pericardial tissue between October 2010 and November 2016. We collected data on the patients’ pathological features, operative characteristics, postoperative outcomes, and survival.ResultsAll six patients were male with an average age of 52 years (range, 18–62 years). Three of the patients had lung cancer, one had stage III thymoma, and two had germinoma. Four of the six patients had mild or moderate superior vena cava compression and no corresponding clinical symptoms. The other two patients had severe compression and obvious symptoms of SVC syndrome, with the typical swelling of the face, eyelids, and upper extremities. All six patients underwent complete tumor resection, with two of the lung cancer patients undergoing right lobectomy and one undergoing right pneumonectomy. With respect to the postoperative outcomes, one patient died, whereas the others did not develop any major complications. At the end of the follow-up period, five of the patients were alive and none of the patients had developed thrombosis in the grafts.ConclusionsOur findings indicated that SVC replacement with autologous pericardium is technically feasible and safe, with few postoperative complications and favorable long-term effects. Although it has some limitations, this method appears to be useful in achieving SVC reconstruction of moderate size. SVC replacement with autologous pericardium appears to have the potential for widespread clinical use.

Haemangioendothelioma: a disease with surgical options from robotic surgery to open superior vena cava replacement

Epithelioid haemangioendothelioma is a malignant tumour of vascular origin that can occur in the mediastinum. Operative treatment techniques may vary depending on the localization. Our goal was to focus on different surgical techniques, ranging from simple stapling of the vascular structure to replacement of the superior vena cava.

Superior vena cava replacement combined with venovenous shunt for lung cancer and thymoma: a case series.

Superior vena cava (SVC) replacement is infrequently performed and technically challenging in low-volume centers. Venovenous shunt (VVS) technique is used to reduce SVC pressure during SVC replacement and has not been well reported. This study aimed to add information on this subject and evaluate the surgical outcomes of patients who underwent SVC replacement combined with VVS in our center. A retrospective analysis of six patients who underwent SVC replacement combined with VVS from September 2011 to February 2017 was performed. Clinical characteristics, pathological features, operative characteristics, postoperative outcomes, and the survival of the six patients were reviewed. There were four males and two females with a median age of 44 years (range, 35-69 years). There were three lung cancer patients and three thymoma patients at a stage from IIIA to IVA. Five patients underwent induction therapy. Complete resection was performed on five patients. One patient underwent internal VVS, and the other five patients underwent external VVS. Prosthesis grafts were employed in five cases and autologous pericardium in one case. Three patients underwent single-vein reconstruction, and the other three patients underwent double-vein reconstruction. The median SVC clamping time was 75 minutes. There were no postoperative deaths or major complications. All patients were alive at follow-up, and no thrombosis was found in any of the grafts. SVC replacement combined with VVS is technically feasible and safe. Although VVS technique is not a must, it may make SVC replacement safer in inexperienced centers. Surgery-based multidisciplinary treatment for selected patients with type T4 lung cancer and SVC involvement or thymoma and SVC involvement may achieve a favorable long-term outcome.

Surgical resection of large anterior mediastinal masses: Results of median sternotomy approach.

e20005 Background: Anterior mediastinal masses are a diverse group of tumors generally presenting as compressive symptoms. Larger masses require open surgical approaches including median sternotomy or sterno-thoracotomy. In this study we analyzed the surgical and pathological outcomes of large anterior mediastinal masses resected through sternotomy approach. Methods: Data of 16 patients with anterior mediastinal masses ( > 10 cms) treated surgically was analyzed retrospectively. All the patients were evaluated preoperatively with MRI, CT guided biopsy and pulmonary function test followed by exploration through median sternotomy approach with/without cardiac bypass (through femoral access). Adjuvant chemo-radiation was used according to histopathological features. Results: A total of 10 male and 6 females with median age 42 years (range: 6-62) underwent resection. Three patients received neoadjuvant chemotherapy and the mean tumor size was 12.2 cms. Histopathologies included mature teratomas/dermoids (4), thymic carcinoma (3), nerve sheath tumors (3), malignant germ cell tumors (3), synovial sarcoma (1) primary mediastinal goiter (1) and inflammatory pseudo tumor (1). There was no postoperative mortality and two patients required cardiac bypass. Bovine pericardium was used in two patients for the loss of large are of pericardium. One patient required biograft for replacement of resected superior vena cava. Major morbidities included prolonged ventilation and intrathoracic collection in two patients. All the patients were disease free after a median follow up of 14 months. Conclusions: Large anterior mediastinal masses are challenging surgically. An aggressive surgical approach through median sternotomy in association with cardiac bypass helps in complete resection and may lead to optimal results.

Resection of the sidewall of superior vena cava using video-assisted thoracic surgery mechanical suture technique.

Lung cancer invading the superior vena cava (SVC) is a locally advanced condition, for which poor prognosis is expected with conservative treatment alone. Surgical resection of the lesion can rapidly relieve the symptoms and significantly improve survival for some patients. Replacement, repair and partial resection of SVC via thoracotomy were generally accepted and used in the past. As the rapid development of minimally invasive techniques and devices, partial resection and repair of SVC are feasible via video-assisted thoracic surgery (VATS). However, few studies have reported the VATS surgical techniques. In this study, we reported the crucial techniques of partial resection of SVC via VATS.

Infiltration of the superior vena cava in NSCLC: results of surgical intervention

The benefits of surgical therapy of locally advanced non-small cell lung cancer (NSCLC) with infiltration of the superior vena cava (SVC) remains controversial. Here we describe our therapeutic approach and results of our intervention.A retrospective analysis of 22 patients with NSCLC who underwent SVC replacement (n = 17) or reconstruction (n = 5) between 1998 and 2013 was performed. Pneumonectomy was necessary in 16 patients, lobectomy in 8. Preoperative chemotherapy was administered to 3 patients, 16 received postoperative radiation treatment. The clinical course and survival were analyzed.Major postoperative morbidities were found in 13 patients. Graft thrombosis did not occur. Thirty-day mortality was 7 % in pneumonectomy patients and 0 % following lobectomy. Local recurrence was found in 4.5 %, distant metastases developed in 54.5 % of the patients (p = 0.0008). One- and five-year survival probabilities for all patients were 63.6 and 27.9 %. Five-year survival probability was 33 % for patients with SVC reconstruction and 25 % for patients with SVC replacement (p = 0.22). Five-year survival rates after pneumonectomy and lobectomy were 21.4 % and 37.5 %, respectively (p = 0.18).Radical resection involving the SVC in carefully selected patients with NSCLC results in excellent local tumor control. Due to the high rate of distant metastases, application of induction and adjuvant chemotherapy should be carefully assessed.

Primary mediastinal pleomorphic liposarcoma involving the superior vena cava.

Primary mediastinal liposarcomas are extremely rare. They are primarily diseases of adults; however, they may be encountered in children. They are characterized by their large size and variable histologic subtypes, which correlate with clinical behavior and prognosis. Although the overall prognosis is poor, it is dependent upon the histologic subtype and completeness of surgical excision. Herein we present a case of a primary mediastinal pleomorphic liposarcoma in a 49-year-old male who received an en-bloc resection and superior vena cava replacement with Gortex graft. The patient has been disease-free after surgery for over 14 months.

胸部肿瘤上腔静脉重建术中脑氧代谢的变化对手术策略选择的指导意义

目的：探讨侵犯上腔静脉的胸部肿瘤手术中手术策略的选择对上腔静脉阻断期间脑氧代谢的影响。方法：总结我院31例胸部肿瘤侵犯上腔静脉合并上腔静脉阻塞及不合并上腔静脉阻塞患者上腔静脉重建术中，直接阻断上腔静脉或旁路分流患者血液动力学改变、脑氧代谢及乳酸改变的情况。结果：上腔静脉阻塞患者术前上腔静脉压力、脑氧摄取率、乳酸水平明显高于不合并上腔静脉阻塞者(24.0 ± 8.9 & 11.0 ± 2.5；36 ± 12 & 29 ± 1O；5.75 ± 2.36 & 3.54 ± 0.88)，而在直接阻断上腔静脉进行重建过程中，上腔静脉压力未见明显升高，脑氧摄取率、静脉乳酸水平无改变，上腔静脉重建开放后腔静脉压力、脑氧摄取率、静动脉乳酸差值明显下降(24.0 ± 8.9 & 14.6.0 ± 6.3；36 ± 12 & 26 ± 12；0.51 ± 1.23 & 0.28 ± 1.21)；未合并上腔静脉阻塞者在进行旁路分流后血液动力学、脑氧代谢率、脑静脉乳酸水平无明显改变。结论：合并上腔静脉阻塞患者在上腔静脉重建过程中直接阻断上腔静脉进行肿瘤切除、腔静脉重建是安全的，未合并上腔静脉阻塞者进行上腔静脉至心房的旁路分流是必要的。Objective: To discuss the effects of the change of oxygen metabolism of the choice of surgical strategy during the superior vena cava reconstruction of thoracic neoplasm. Method: 31 patients underwent superior vena cava replacement from 2006 to 2013. The superior vena cava was totally obstructed in 12 patients and was partially involved in 19 patients. During the SVC replacement, the SVC were directly clamped in the SVCOS patients, and bypassed through the temporary SVC to right atrial bypass graft. The hemodynamic indexes, jagular oxygen index, and blood lactate were monitored during the operation. Results: SVC pressure, was significantly higher in the SVCO pa-tients before the operation than the non-SVCO patients (24.0 ± 8.9 mmHg & 11.0 ± 2.5 mmHg), and decreased significantly after SVC reconstruction (24.0 ± 8.9 mmHg & 14.6.0 ± 6.3 mmHg). The ce-rebral oxygen extraction rate, venous-arterial oxygen content difference and the jagular vein blood lactate level were significantly higher in the SVCOS patients comparing with no SVCO patients (36 ± 12 & 29 ± 1O; 0.51 ± 1.23 & 0 ± 0.21; 5.75 ± 2.36 & 3.54 ± 0.88), and decreased significantly after SVC replacement (36 ± 12 & 26 ± 12; 0.51 ± 1.23 & 0.28 ± 1.21; 5.75 ± 2.36 & 3.86 ± 1.75). The he-modynamic indexes and oxygen metabolism indexes were stable during the direct clamp of SVCO patients and bypass procedure of non-SVCO patients. Conclusion: The direct clamp of SVC for SVCO patients was safe and the efficacious bypass between SVC and right atrium was essential for non- SVCO patients during the SVC replacement of thoracic neoplasm.

Reconstruction of the Superior Vena Cava by Biologic Conduit: Assessment of Long-Term Patency by Magnetic Resonance Imaging

To assess the long-term patency of the biologic prosthetic conduit used for reconstruction of the superior vena cava (SVC) by magnetic resonance imaging (MRI). Patients undergoing oncologic resection and reconstruction of the SVC by a bovine pericardial prosthesis (January 2003 to April 2010) have been studied after 1 year (if surviving) by MRI for the assessment of the conduit long-term patency. Results were compared with those of a control group of patients with normal SVC. Blood flow and area of lumen section at 3 different levels (proximal, middle, distal) were analyzed. Sixteen consecutive patients surviving after 1 year from surgery out of 17 (9 lung cancer, 8 mediastinal malignancy) undergoing SVC reconstruction were included. One patient died postoperatively and was not included. Sixteen patients with similar demographic characteristics were studied in the control group. Mean blood flow was 18.4±3.5 mL/sec (range 14.3 to 25.7) in patients with reconstructed SVC and 20.8±4.1 mL/sec (range 15.3 to 27.7) in the control group. Mean area of the conduit lumen section was 2.2±0.6 cm2 (range 1.6 to 3.6) at proximal level, 2.9±1.3 cm2 at middle level (range 1.3 to 5.7), and 2.1±0.9 cm2 (range 0.5 to 4) at distal level in the reconstructed group, and 2.6±0.7 cm2 (range 1.8 to 4.2), 2.7±0.7 cm2 (range 1.9 to 4.3), and 2.4±0.3 cm2 (range 1.8 to 3.1), respectively, at proximal, middle, and distal levels in the control group. Differences between the 2 groups were not significant (p>0.05). The MRI assessment in terms of blood flow and area of lumen section at 3 different levels confirms that bovine pericardial conduit used for SVC replacement shows an optimal patency over the long term.

Long-Survival Case of Thymic Carcinoma With Superior Vena Cava Tumor Thrombus

Sarcomatoid carcinoma of the thymus is rare and responds poorly to treatment. Invasion of great vessels and metastasis are significant predictors for poor prognosis. Thymic tumors commonly cause superior vena cava (SVC) obstruction by extrinsic compression or invasion, but intraluminal permeation is the most uncommon cause. We report a rare, long-surviving case of sarcomatoid carcinoma with SVC syndrome developed by tumor thrombus. She underwent SVC replacement and extended thymectomy. The resection indicated intracaval extension without direct invasion of thymic tumor, histologically diagnosed as sarcomatoid carcinoma. After adjuvant chemotherapy, she continues to show no apparent recurrence for five years.

Long-term patency of the stapled bovine pericardial conduit for replacement of the superior vena cava

Artificial prosthesis of the superior vena cava (SVC) may occlude with time. For this reason, we proposed in 2003 the use of a biological material (bovine pericardium) and devised an original technique to construct the prosthetic conduit. We hereby report the long-term results in 15 patients. The SVC prosthetic conduit is realized by wrapping a bovine pericardial leaflet around a 5 or 10 cm(3) syringe and stapling it on the side by a 60-80 linear stapler. This procedure is carried out intra-operatively after the size of the patient's SVC has been ascertained; the conduit is then cut to the appropriate length. We have employed this technique in 15 patients with lung (eight) or mediastinal (seven) tumors; after a minimum follow-up of 1 year, all patients underwent computed tomographic-volume rendering (CT-VR) studies of the SVC. Technically, the stapled pericardial conduit has several advantages: (1) it is simple and expeditious; (2) it allows an even and regular suture line, which cannot be achieved by hand suturing; (3)'one size fits all': with one single pericardial leaflet, conduits of all sizes can be realized; this is important for an operation which is performed only few times per year; (4) patency is granted by the intrinsic rigidity of the pericardium and staple line, without the need for any reinforcement; (5) different calibers at the two extremities can be obtained by simply placing the stapler obliquely; and (6) the staple line is excellent for the orientation of the conduit while suturing. In our patients, SVC clamping time ranged between 18 and 50 min (mean 29 min); one patient needed cardiopulmonary bypass. Intra-operative anticoagulation (1.500-2.500 units of heparin) was continued postoperatively subcutaneously for 7 days and then shifted to oral anticoagulation for 6 months. One patient died postoperatively of heart failure (mortality 6%). One to 5 years after surgery, CT-VR showed full patency of the pericardial conduit, no clots or thrombus formation, and absence of collateral venous circulation in all 14 patients. One- and 5-year survival was 93% and 73%, respectively (Kaplan-Meier). The stapled bovine pericardial conduit is a simple, expeditious, and economic solution to SVC replacement, and offers reliable long-term patency without permanent anticoagulation.

Evaluation of resection of local advanced upper lung cancer through median sternotomy

To summarize the resection of local advanced upper lung cancer and radical bilateral mediastinal lymph node dissection through a median sternotomy. A total of 31 patients with local advanced upper lung cancer underwent lobectomy and radical complete dissection of bilateral superior mediastinal lymph node through a median sternotomy (the sternotomy group). The sternotomy group consisted of 8 females and 23 males, from 35 to 75 years old (average 57 years). Five patients underwent superior vena caval replacement or partial excision, 21 underwent upper sleeve lobectomy, and 6 patients combined with right pulmonary artery sleeve angioplasty or partial resection and reconstruction. Compared with the 30 patients who were operated through posterolateral incision, the surgery time, complications, and prognosis during the same period (the posterolateral incision group) were recorded. There was no perioperative death. The average operation time in the sternotomy group was (170±30)min, while that in the posterolateral incision group was (140±30) min(P>0.05). Postoperative complications comprised atelectasis, cardiac arrhythmia, and pneumonia. In the sternotomy group it was 6.5%(2/31), 16.1%(5/31), and 6.5% (2/31),and that in the posterolateral incision group 3.3%(1/30), 20%(6/30), 10.0%(3/30),respectively. Postoperative pathological findings demonstrated the rate for pN3 disease in the sternotomy group was 29%(9/31), 2 patients died of brain and liver metastasis respectively 10 or 11 months after the operation. The 3 year survival rate of 9 patients with pN3 diagnosed as cN2 preoperatively was 33.3%(3/9). The total survival rate of 1,3 years in the sternotomy group was 90.3%(28/31) and 41.9%(13/31), in the posterolateral incision group 86.6%(26/30) and 40.0%(12/30),respectively(P>0.05). Median sternotomy helps to resect local advanced upper lung cancer completely and to dissect bilateral mediastinal lymph node, and it can also provide more complete postoperative lymph node staging with no significant increase in complications.

A simple bypass technique for superior vena cava reconstruction☆

Superior vena cava (SVC) clamping can be required during thoracic surgery for SVC replacement or repair. In such cases, bypass techniques can be necessary to avoid hemodynamic instability, cerebral venous hypertension and hypoperfusion. Here, we report a novel and simple SVC bypass technique which does not require full systemic heparinization, specialized cannulation techniques or pumping devices and which can be applied percutaneously in the preoperative phase or intraoperatively. The preoperative shunt consisted in two Swan-Ganz catheters inserted in the jugular and femoral veins and connected by perfusion tubing with a three way stopcock. The intraoperative shunt consisted of a Pruitt(®)-catheter inserted in the left innominate vein and connected to a femoral Swan-Ganz catheter by perfusion tubing. We validated our system in seven patients undergoing SVC reconstruction. We monitored the systemic arterial blood pressures, the heart rate and vasoactive peptide requirements throughout the procedure. We also determined the neurological status and the in-hospital morbidity and mortality for each patient. Using this bypass, SVC clamping caused no hemodynamic instability, no neurological impairments and no in-hospital complications or deaths. This simple temporary SVC bypass procedure is safe and avoids hemodynamic instability and cerebral venous hypertension.

Superior vena cava resection in thoracic malignancies: does prosthetic replacement pose a higher risk?☆

After superior vena cava (SVC) resection, the need for reconstruction varies among tangential resection, pericardial patch repair and prosthetic replacement. Patients undergoing complete prosthetic replacement often require a different surgical approach, intra-operative SVC cross-clamping and anticoagulation when polytetrafluoroethylene (PTFE) prosthesis is used. This study tested the hypothesis that PTFE replacement may interfere with perioperative outcome. Clinical records from a series of 72 consecutive SVC resections performed between 1998 and 2008 were reviewed. Complications were classed into five categories: surgical, respiratory, cardiac, SVC system thrombosis and nerve damage. Each category of postoperative complications was considered as an outcome variable in a univariate analysis testing 12 covariates as risk factors. Covariates considered clinically relevant or statistically significant were included in the multivariate model. During the considered period, 28 patients underwent total SVC resection with PTFE prosthetic replacement and 44 patients underwent SVC repair by the use of direct running suture (nine patients), stapling (30 patients) or autologous pericardial patch (five patients). Two patients died postoperatively (2.8%). Major complications were mainly due to respiratory failure, which occurred in nine cases (acute respiratory failure in five cases, recurrent atelectasis in three cases, acute respiratory distress syndrome (ARDS) in one case). In terms of overall mortality and morbidity, univariate analysis did not confirm a detrimental effect of SVC replacement as compared with SVC repair, as major postoperative complications occurred in similar proportion in both groups (respectively, 6/28, 21.4% vs 7/44, 15.9%, p=0.54). No other risk factor was identified by univariate analysis. Complete prosthetic replacement does not increase overall postoperative morbidity in patients undergoing SVC resection and can be safely performed when other reconstruction techniques preclude sufficient tumour-free resection margin or compromise adequate blood flow.

Results of Primary Surgery With T4 Non–Small Cell Lung Cancer During a 25-Year Period in a Single Center: The Benefit is Worth the Risk

The purpose of this study was to assess operative mortality, morbidity, and long-term results of patients with surgically resected T4 non-small cell lung carcinoma. A retrospective review of 271 patients with T4 non-small cell lung carcinoma between 1981 and 2006 was undertaken. They were divided into four subgroups: 126 patients with superior sulcus tumors, 92 with carinal involvement, 39 with superior vena cava replacement, and 14 with the tumor invading other mediastinal structures. There were 221 men and 50 women with a mean age of 56.3 years. Resection was complete in 249 (92%) patients. The pathologic N status was N0/N1 in 208 and N2/N3/M1 in 63 patients. Operative mortality and morbidity rates were 4% and 35%, respectively. Overall 5-year survival rate was 38.4%. It was 36.6% for superior sulcus tumor, 42.5% for carinal involvement, 29.4% for superior vena cava replacement, and 61.2% for mediastinal group. By multivariate analysis, only three factors influenced survival: nodal status (N0/N1 versus N2/3/M1; 43% versus 17.7% at 5 years, respectively; p = 0.01), complete resection (R0 versus R1; 40.4% versus 15,9%, respectively; p = 0.006), and invasion of the subclavian artery (with versus without invasion; 24.9% versus 41.7%, respectively, p = 0.02). In highly qualified centers, radical surgery of T4 N0/N1 non-small cell lung carcinoma can be performed with a 4% mortality rate and may yield a 43% 5-year survival rate. These results seem to indicate primary surgery as the treatment of choice for T4 non-small cell lung carcinoma, whenever a complete resection is thought to be technically feasible and the patient's condition is compatible with the extent of the planned surgery.