Superior Vena Cava Resection Research Articles

Prosthesis selection for reconstruction of superior vena cava: comparison of midterm patency rates.

This study compared the mid-term patency of expanded polytetrafluoroethylene grafts without rings versus that of bovine pericardial conduits used for superior vena cava reconstruction for various thoracic diseases. Among 80 patients who underwent superior vena cava resection and reconstruction between 2009 and 2023 at our institution, 31 patients who received polytetrafluoroethylene grafts without rings(Polytetrafluoroethylene group) and 28 patients who received bovine pericardial conduits(Bovine group) were enrolled. Median follow-up durations were 19.5 and 64.6 months in Polytetrafluoroethylene and Bovine groups, respectively. Primary outcome was midterm graft patency rate, and secondary outcomes were early and midterm clinical outcomes including all-cause mortality and superior vena cava reintervention. Operative mortality was 1.7%. Cumulative incidence of all-cause mortality was not significantly difference between the groups. Graft occlusion was detected in 22 patients. Cumulative incidence of graft occlusion was 24.2%, 36.4%, 42.4%, 48.5%, and 60.6% at 1 month, 3 months, 6 months, 1 year, and 2 years, respectively, in Bovine group, whereas no graft occlusion was observed in Polytetrafluoroethylene group(P=0.007). Although the incidence of graft occlusion was higher in Bovine group, cumulative incidence of reintervention was not significantly different between the groups(0.0% vs. 3.0% in Polytetrafluoroethylene vs. Bovine groups at 1 year, P=0.406). Multivariate analysis demonstrated that bovine pericardial conduit(Polytetrafluoroethylene graft as reference) and left brachiocephalic vein reconstruction(right brachiocephalic vein reconstruction as reference) were significant risk factors for graft occlusion. In superior vena cava reconstruction, polytetrafluoroethylene grafts without rings were superior to bovine pericardial conduits in terms of midterm graft patency.

Internal jugular vein pressure monitoring guided venous reconstruction could improve perioperative safety after superior vena cava resection for mediastinal tumors: a cohort study.

After superior vena cava (SVC) resection, the decision on unilateral or bilateral reconstruction was mostly based on the expertise of surgeons without objective measurements. This study explored the use of internal jugular vein pressure (IJVP) monitoring to guide the SVC reconstruction strategy. In a retrospective cohort, perioperative outcomes of unilateral and bilateral reconstruction based on surgeons' experience were compared. Then, IJVP threshold was measured when temporarily clamping the left innominate vein in a testing cohort. Venous reconstruction according to IJVP monitoring was performed in a prospective validation cohort afterward. Perioperative outcomes were compared between the prospective and the retrospective cohorts. For some interested variables, intuitive explanations would be given using Bayesian methods. Potential risk factors for postoperative complications were investigated by multivariable analysis. From March 2009 to September 2022, 57 patients underwent SVC reconstruction based on surgeons' experience. Bayesian analysis indicated a posterior probability of 80.49% that unilateral reconstruction had less blood loss than bilateral reconstruction (median 550ml vs. 1200ml). Cerebral edema occurred in two patients after unilateral reconstruction. In the testing cohort, median IJVP was 22.7 (18-27) cmH 2 O after temporary left innominate vein clamping in 10 patients. In the prospective cohort, unilateral reconstruction only was performed if the contralateral IJVP was <30cmH 2 O in 16 patients. Bilateral reconstruction was performed if IJVP was ≥30cmH 2 O after unilateral bypass in nine patients. No cerebral edema occurred in the prospective cohort. Less postoperative complications occurred in the prospective cohort than the retrospective cohort (12.0 vs. 38.6%, P =0.016). Upon multivariable analysis, IJVP-monitoring guided SVC reconstruction was associated with significantly less postoperative complications ( P =0.033). Intraoperative IJVP-monitoring is a useful strategy for selection of unilateral or bilateral SVC reconstruction and improving perioperative safety in patients with mediastinal tumors.

A Multicenter Retrospective Cohort Study on Superior Vena Cava Resection in Non-Small-Cell Lung Cancer Surgery.

Surgery for non-small-cell lung cancers (NSCLCs) invading the superior vena cava (SVC) is rarely performed due to surgical complexities and reported poor prognoses. Different methods have been described to reconstruct the SVC, such as direct suture, patch use or prosthesis, according to its circumferential involvement. The aim of our study was to analyze the short- and long-term results of different types of SVC resection and reconstruction for T4 NSCLCs. Between January 2000 and December 2019, 80 patients received an anatomical lung resection with SVC surgery in this multicenter retrospective study. The partial resection and direct suture or patch reconstruction group included 64 patients, while the complete resection and prosthesis reconstruction group included 16 patients. The primary endpoints were as follows: long-term survival and disease-free survival. The secondary endpoints were as follows: perioperative complications and 30- and 90-day mortality. Unpaired t-tests or Mann-Whitney U tests for non-parametric variables were applied to discrete or continuous data, and the chi-square test was applied to dichotomous or categorical data. Survival rates were calculated using the Kaplan-Meier method and compared using the log-rank test. No differences were found between the two groups in terms of general characteristics and surgical, oncological and survival outcomes. In particular, there were no differences in terms of early (50.0% vs. 68.8%, p = 0.178) and late complication frequency (12.5% vs. 12.5%, p = 1.000), 30- and 90-day mortality, R status, recurrence, overall survival (33.89 ± 40.35 vs. 35.70 ± 51.43 months, p = 0.432) and disease-free survival (27.56 ± 40.36 vs. 31.28 ± 53.08 months, p = 0.668). The multivariate analysis demonstrated that age was the only independent predictive factor for overall survival. According to our results, SVC resection has good oncological and survival outcomes, regardless of the proportion of circumferential involvement and the type of reconstruction.

Artificial reconstruction for a thymoma invading superior vena cava

Artificial reconstruction for a thymoma invading superior vena cava

A case of thymic carcinoma resected by preserving collateral circulation tract via azygos vein with combined resection of superior vena cava and bilateral brachiocephalic vein

A case of thymic carcinoma resected by preserving collateral circulation tract via azygos vein with combined resection of superior vena cava and bilateral brachiocephalic vein

A technique of revascularization in mediastinal tumor surgery with superior vena cava resection

A technique of revascularization in mediastinal tumor surgery with superior vena cava resection

Superior vena cava resection and plastic repair as a part of surgical and combined treatment of lung cancer

This article summarizes our own experience of reconstructive operations with resection and plastic repair of the superior vena cava in the field of locally advanced lung cancer surgery. Both technical aspects and methodological approaches of this type of combined interventions are described in detail. Data from 45 patients who underwent wedge (21) and circular (24) superior vena cava resections were analyzed. In most (65%) cases, venous resection and reconstruction were combined with multi-organ resections of other anatomical structures of the chest cavity. 87% of patients received combined treatment in different directions. Postoperative complications were registered in 40% of cases, and the mortality rate was 13%. The unfavorable postoperative prognostic factors were followings: old age, pneumonectomy, combination of vein angioplasty with carinal resection. The 5-year survival rate was 18.5%, with a median survival of 19.4 + 4.6 months. The results allow us to recommend such operations in highly specialized clinics that have extensive experience in tracheobronchial angioplastic surgery and highly-qualified anesthesia care providers. Multimodal treatment allows to achieve satisfactory long-term results.

Outcomes and Safety Analysis in Superior Vena Cava Resection for Extended Thymic Epithelial Tumors

In stage III to IVa thymic epithelial tumors (TETs), infiltration of the superior vena cava (SVC) is not rare. The extent of SVC resection depends on the width of the area of neoplastic invasion. Our article aims to evaluate the safety and long-term outcomes of extended thymectomy for TETs with SVC resection compared with advanced-stage TETs patients without SVC resection. Retrospective review of the experience on patients who underwent extended thymectomy for TETs in the last 20 years, according to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) methodology. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method. A backward stepwise Cox regression multivariate analysis was performed to determine factors associated with long-term outcomes. A total of 78 patients underwent surgery for advanced-stage TETs (Masaoka-Koga stages III-IVa) from January 1998 to April 2019. Fourteen (17.9%) underwent thymectomy with resection of SVC. Presence of a thymic carcinoma (hazard ratio , 2.26; 95% confidence interval, 1.82-6.18; P= .038) and the SVC resection (hazard ratio, 1.89; 95% confidence interval, 1.11-3.96; P= .041) were adverse prognostic factors at multivariate analysis. The median OS and the PFS of all SVC resected patients were 50 (range, 5-207) months and 31 (range, 5-151) months, respectively. There was no significant difference in OS (P= .28) and PFS (P= .32) between SVC-resected and non-SVC-resected patients. SVC resection is a safe and effective procedure to restore the venous system continuity and does not seem to affect survival and disease recurrence. This surgical approach allows radical resection of locally advanced TETs, even after neoadjuvant chemotherapy.

Superior Vena Cava Resection in Locally Advanced Thymoma-Surgical and Survival Outcomes.

This study was aimed at reporting the surgical management of superior vena cava invasion in patients with locally advanced thymoma and to evaluate surgical and survival outcomes. This is a retrospective analysis of 12 patients operated for superior vena cava resection for locally advanced thymoma over 8years in a thoracic surgery centre in India. An analysis of peri-operative variables including complications was carried out. The influence of various predictors on survival was assessed by log-rank test. Intra-operatively, superior vena cava (SVC) alone was involved in 3 (25%) cases, SVC with BCV involvement was there in 8 cases (66.7%) and in 1 patient, the SVC involvement extended into the right atrium also. In all cases, the tumour was resected en bloc with the involved part of SVC. Repair with primary closure was sufficient in 2 cases (16.6%) in view of < 1/3rd of circumferential involvement. However, in remaining 10 cases, SVC was replaced with PTFE graft (single graft in 6 cases, Y-graft in 2 cases and twin grafts in 2 cases). No peri-operative deaths. Overall survival (OS) at 1, 3 and 5years was 100%, 91.6% and 83.3%, respectively. Myasthenia gravis and higher Masaoka stage (IV A) of the disease were poor predictors of survival. Superior vena cava resection and reconstruction is a feasible and oncologically superior option in invasive thymoma with SVC involvement. This challenging surgical procedure should only be attempted by an experienced team of thoracic and cardiac surgeons at high-volume centre to achieve best outcomes.

An Unusual Case of Thymoma Invading SVC Excised Completely Enbloc with SVC Resection and Reconstruction

We report a challenging rare case of stage III large thymoma with superior vena cava (SVC) invasion but without SVC syndrome or myasthenic symptoms. The tumor responded poorly to neo-adjuvant VAC chemotherapy so was referred for surgical resection. We successfully performed the complex Enblock resection of the tumor with SVC, lung, phrenic and pericardium without requiring cardiopulmonary bypass followed by reconstruction of the SVC and innominate vein with the Gore-Tex graft.

Results of superior vena cava resection in patients with lung and mediastinal tumors

Background: Thoracic tumors involving the superior vena cava (SVC) are common in the practice of a thoracic surgeon treating cancer patients. Extended combined procedures that allow for complete removal of the tumor improves overall and disease-free survival and as such are justified from an oncologist’s perspective. In some patients, due to a long-standing SVC syndrome, the development of venous collaterals would increase the early postoperative risk of thrombus formation in the prosthesis. In such a case, it is possible to perform circular SVC resection without subsequent prosthetic replacement. Aim: To evaluate the short-term results of SVC resection in patients with chest tumors, to develop an algorithm and to identify the patient group in whom circular SVC without prosthetic replacement is feasible. Materials and methods: Twenty eight (28) patients were included into the study (22 men and 6 women, with the mean age of 55 [range, 21 to 70 years]; all of them had undergone SVC resection within the intervention for a lung or mediastinal malignancy for 10 years (from 2008 to 2018) in the Department of Thoracic Surgery, Moscow Research Institute of Oncology named after P.A. Herzen. We analyzed their short-term results of the procedures, the postoperative course, and technical particulars of the procedures. Results: Locally advanced lung cancer was diagnosed in 19 (67%) of the patients, thymoma in 3 (10%), lung metastatic disease in 2 (7%), germ-cell mediastinal tumors in 2 (7%), thymus cancer in 1 (3%), and residual lymphoma in 1 (3%) patient. In the majority of the patients (15 cases, 53%), the complicated clinical course had been diagnosed before surgery. In 4 patients with protracted SVC syndrome, we performed circular resection without any prosthetic replacement. In 22 patients (78%), the postoperative course was uneventful. Postoperative mortality was 7%. Conclusion: SVC resection can be safely performed in patients with primary mediastinal and lung tumors. With a long-standing SVC syndrome, the newly developed cava-caval anastomoses can provide significant functional support; in such patients with compensatory collateral blood flow, the circular SVC resection without prosthetic replacement is relatively safe.

Thoracoscopic thymectomy with partial superior vena cava resection for locally advanced thymomas.

Video-assisted thoracoscopic surgery (VATS) is now increasingly used for the treatment of early stage thymic malignancies. However, VATS has not been advocated for patients with locally advanced diseases. We reviewed our initial experience in VATS thymectomy with partial superior vena cava (SVC) resection for IASLC/ITMIG stage III thymic tumors. From August 2017 to October 2018, patients who underwent VATS thymectomy with partial SVC resection were retrospectively reviewed, and peri-operative outcomes and short-term follow-up results were analyzing. Four patients with partial SVC resection via VATS were identified. All of them had pathologically confirmed IASLC/ITMIG stage III thymic tumors invading the SVC. The average of operative time was 228 minutes and mean blood loss was 88 mL. The mean duration of chest tube drainage and post-operative hospital stay were 4.5 and 7.3 days respectively. No major complication was encountered after surgery. No mortality was observed. And no recurrence was detected with the longest follow-up time of 14 months. With careful patient selection and plenty surgical expertise, VATS thymectomy for locally invasive thymic tumors with limited the SVC invasion is challenging yet technically feasible.

Carinal surgery: A single-institution experience spanning 2 decades

ObjectivesComplete resection of neoplasms involving the carina are technically challenging and have high operative morbidity and mortality. This study examines the last 2 decades of clinical experience at our institution. MethodsMedical records were retrospectively reviewed between 1997 and 2017 to identify all patients who underwent carinal resection. Primary outcome measures include risk factors for complications and overall survival. ResultsIn total, 45 carinal resections were performed with a median follow-up of 3.4 years (interquartile range 0.8-8.5). Procedures included 21 neocarinal reconstructions (48%), 14 right carinal pneumonectomies (30%), 9 left carinal pneumonectomies (20%), and 1 carinal plus lobar resection (2%). Age ranged from 27 to 74 years, and 23 of 45 patients were female. Eight received neoadjuvant chemotherapy and 6 preoperative radiation. Extracorporeal membrane oxygenation and cardiopulmonary bypass were intraoperatively used for 4 patients with no mortality. Four patients underwent superior vena cava resection and reconstruction. Anastomotic complications occurred in 5 patients, all of which were managed conservatively: 1 required stent placement and a second underwent hyperbaric oxygen therapy. Postoperative events were observed in 26 patients (58%), including pneumonia (n = 11), blood transfusion (n = 8), and atrial arrhythmias (n = 8). More serious complications, such as acute respiratory distress syndrome, occurred in 3 patients. Postoperative events were most closely associated with pulmonary resection (P = .040). There were 3 deaths, yielding an overall operative 30- and 90-day mortality of 6.8% and 7%, respectively. ConclusionsDespite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Preoperative chemotherapy, radiation, and concomitant pulmonary resection were associated with increased risk of complications. Patient selection and meticulous surgical technique contribute to reduction in morbidity and mortality.

Superior Vena Cava Replacement for Thymic Malignancies

Advanced-stage thymic tumors infiltrating the superior vena cava (SVC), when radically resectable, can be surgically treated by SVC prosthetic replacement within a multimodality therapeutic approach. We hereby present our series of patients undergoing SVC resection and prosthetic reconstruction for stage III or IV thymic malignancies. Between 1989 and 2015, 27 patients with thymic tumors (21 thymoma, 6 thymic carcinoma) infiltrating the SVC underwent radical resection with a SVC prosthetic replacement by a bovine pericardial conduit in 12 cases, a polytetrafluoroethylene conduit in 13, a porcine pericardial conduit in 1, and a saphenous vein conduit in 1. All the patients underwent vascular conduit reconstruction by the cross-clamping technique. Six patients were myasthenic. All resections were complete (R0). Twelve patients received induction treatment. Pulmonary resection was associated in 16 patients (11 wedge, 5 pneumonectomy). Twenty-two patients were Masaoka stage III and 5 were stage IVa. Mortality rate was 7.4%; no mortality was related to the vascular reconstruction. Major complication rate was 11.1%. At a median follow-up of 58 (range, 4 to 134) months, recurrence occurred in 9 (36%) patients. Three- and 5-year overall survival rates were 80% and 58.1%, respectively. Three-and 5-year cancer-specific survival were 90.5% and 75.4%. Cancer-specific survival rates of thymoma patients at 5 years were 93.8%. Five-year cancer-specific survival of all stage III patients was 77.1%. Thymic carcinoma histology was a negative prognostic factor. Long-term patency of the pericardial conduits was 100%. En bloc resection and conduit reconstruction of the SVC is a good option to allow radical resection of locally advanced thymic tumors. A heterologous pericardial conduit represents the favorite option in our experience.

Right tracheal sleeve pneumonectomy and superior vena cava resection and reconstruction with bovine pericardial patch

Right tracheal sleeve pneumonectomy and superior vena cava resection and reconstruction with bovine pericardial patch

Superior vena cava (SVC) resection and reconstruction in non-small cell lung cancer (NSCLC) invasion

Non-small cell lung cancer (NSCLC) infiltrating the superior vena cava (SVC) is a formidable challenge to surgeons in view of significant post-operative morbidity and mortality. Primary tumor infiltration is more common than the involvement by the mediastinal lymph-nodes. However, en bloc resection of SVC, whether partial or circumferential, along with the tumor in appropriately selected patients to achieve oncologically safe resection has acceptable perioperative morbidity, mortality and 5-year survival rates. The aim of this review article is to describe the rationale, the surgical techniques and the outcome in patients with NSCLC involving the SVC.

Superior vena cava resection and reconstruction in mediastinal tumors and benign diseases.

This study aims to evaluate our results of resection and reconstruction of the superior vena cava invaded by mediastinal tumors and benign diseases. Seventeen patients (8 males, 9 females; mean age 46±17 years; range 9 to 74 years) undergoing superior vena cava resection and reconstruction due to mediastinal pathologies between September 2006 and September 2016 were retrospectively reviewed. Patients who had angioplasty with primary suturing or partial resection with stapler were excluded. Mortality and morbidity rates were analyzed based on the demographic, and intra- and postoperative measures. Majority of patients (94%) had mediastinal tumors. Twelve patients (71%) had thymic epithelial tumors. Tubular graft interposition was performed using ringed polytetrafluoroethylene prosthesis in nine patients (53%), while patch plasty using autologous pericardium, polytetrafluoroethylene or Dacron grafts was performed in eight patients (47%). Eleven patients (65%) necessitated concomitant resections of neighboring structures. Mean length of hospital stay was 11±6 days. There was no intraoperative death. Mortality occurred in three patients (18%). Five patients (29%) developed complications. Mortality occurred commonly in elderly patients (p<0.0001). Postoperative complications were more common in patients with concomitant resections (p=0.05). Neither acute nor chronic thrombosis developed in any patients. Median survival in patients with malignant diseases was 57 months, with a oneyear and three-year probability of survival of 83% and 74%, respectively. Replacement of superior vena cava should be included in the therapeutic algorithm of selected patients with mediastinal tumors and benign diseases. Mortality rates may be higher in older patients, while the need for concomitant resections may increase morbidity rates.

Is Surgery after Chemoradiotherapy Feasible in Lung Cancer Patients with Superior Vena Cava Invasion?

Purpose: The purpose of this study is to explore the possibility of surgery after chemoradiotherapy (CRT) for locally advanced-non-small-cell lung cancer (LA-NSCLC) with superior vena cava (SVC) resection in terms of prognosis and early and late postoperative course.Methods: The medical records of NSCLC patients who underwent surgery after CRT at our institution between January 2001 and March 2016 were reviewed. We evaluated the feasibility of surgery with SVC resection after CRT.Results: A total of 8 LA-NSCLC patients were enrolled in this study. The SVC management included a graft replacement in two patients, pericardial patch repair in two, and direct suture closure in four. A complete resection was achieved in seven of the eight patients (87.5%). Postoperative early and late complication rate (Clavien-Dindo classification ≥ grade III) was 25%. All the complications were manageable, and no treatment-related deaths occurred in this series. Although seven out of eight patients showed good patency of reconstructed SVC, one patient exhibited the SVC occlusion during long-term follow-up period. Regarding the prognosis, the 5-year overall survival (OS) rate was 60.0%, and the 2-year recurrence-free survival (RFS) rate was 75.0%.Conclusion: Our results suggest that surgery with SVC resection after CRT is a feasible procedure in terms of clinical outcomes and postoperative course.

Surgical treatment of lung tumors with superior vena cava infiltration

Introduction. Direct malignant invasion by primary lung tumors or by nodular metastases is the most frequent indication for superior vena cava resection and reconstruction. The aim of our work is to underline the importance of good evaluation and preoperative workup from the standpoint of the overall survival. Case outline. A male patient, aged 61 years, was admitted for the surgical treatment of adenocarcinoma of the right lung upper lobe. The proposed protocol for the treatment of our patient comprised radiological verification, biopsy with histopathology analysis, standard upper lobectomy with mediastinal lymphadenectomy and with resection of the superior vena cava in a length of about 30 mm. Reconstruction of the superior vena cava was done by implanting a 16 mm INTERGARD vascular graft, using the running suture. In our patient, grafting and bridging the superior vena cava structure prevented the development of postoperative vascular complications and improved survival from the beginning of the treatment. Conclusion. Mixed thoracic and vascular surgical treatment reduces postoperative complications and improves survival.

Early and Long-Term Results of Tracheal Sleeve Pneumonectomy for Lung Cancer After Induction Therapy

The role of induction therapy (IT) and its effects on morbidity and mortality of patients receiving tracheal sleeve pneumonectomy (TSP) are unclear. We evaluated early and long-term outcomes of patients who underwent TSP after IT. From 1998 to 2015, 32 patients (26 men; median age, 63 years) underwent TSP. Twenty-two patients (69%) received IT (cisplatin-based chemotherapy). The TSPs were all right sided and included three completion pneumonectomies. Superior vena cava resection was combined with TSP in 15 cases. Diaphragmatic and vertebral resection was also associated in 1 case each. Operative mortality was nil. Thirty-day mortality was 9% (n= 3). Major complications occurred in 7 patients (21.8%): bronchopleural fistulas in 3; acute respiratory distress syndrome in 2; cardiac hernia in 1; and empyema in 1. The IT had no significant effects on morbidity and mortality. Resection was complete in 31 patients (97%). Pathologic N status was N0 in 2 cases, N1 in 17, and N2 in 13. Nodal downstaging was diagnosed in 13 of 22 patients (59.1%) who received IT (11 passed from N2 to N1, and 2 to N0). Mean survival was 36 months (range, 1 to 181). Overall 5-year survival and disease-free survival were 30.3% and 27.7%, respectively. Patients receiving IT had a poor survival (p= 0.03). At multivariate analysis, nodal downstaging and adjuvant treatment significantly affected survival (p= 0.035 and p= 0.007, respectively). Tracheal sleeve pneumonectomy is a feasible but technically challenging surgical procedure and provides acceptable results in terms of early and long-term outcomes. Induction therapy did not significantly affect morbidity and mortality.