Vena Cava Obstruction Research Articles

Ligation of the suprarenal vena cava and right nephrectomy with complete recovery

A review of the literature on inferior vena caval obstruction above the renal veins is made. This demonstrates only one case of survival after right nephrectomy and ligation of the inferior vena cava above the renal veins. The case presented here is the only one reported with survival after trauma and right nephrectomy and ligation of the inferior vena cava above the renal veins. This suggests that ligation of the vena cava above the renal veins is not as fatal a procedure as it had been thought to be. A review of the literature on inferior vena caval obstruction above the renal veins is made. This demonstrates only one case of survival after right nephrectomy and ligation of the inferior vena cava above the renal veins. The case presented here is the only one reported with survival after trauma and right nephrectomy and ligation of the inferior vena cava above the renal veins. This suggests that ligation of the vena cava above the renal veins is not as fatal a procedure as it had been thought to be.

Progressive Fibrosing Mediastinitis

report entitled “Mediastinal Tuberculoma” published by Samson et al. [16] in 1950 directed surgical attention to the problem A of benign mediastinal adenopathy. Two of the patients in their report had symptoms of airway obstruction, and a third patient had a firm cervical mass fixed to the trachea. The pathological process was identical in the three patients. Specimens consisted of granulomatous masses containing central areas of caseation and peripheral bands of dense hyalinized fibrous tissue, with scattered foci of calcification, zones of epithelial cells, and occasional giant cells. Tuberculosis was not proved in any of these patients. Mediastinal granuloma was the term applied to a similar pathological pattern occurring in patients reported by Kunkel et al. [l 11 in 1954. One of Kunkel’s patients who suffered with severe airway obstruction was considered inoperable. A second patient was treated for mitral stenosis, yet autopsy disclosed a subcarinal keloid type of reaction obstructing most of the pulmonary veins. These authors implied that such fibrosis might be the end result of granulomatous disease within the mediast inum. Gillespie’s report [7] of superior vena caval obstruction in a 7-yearold child appeared in 1956. In this patient vena caval obstruction developed as the residuum of a right pulmonary parenchymal infiltrate which was accompanied by positive histoplasmin skin tests and positive histoplasmin serology in high dilution. The symptoms of vena caval obstruction were completely alleviated by excising a portion of the dense fibrous tissue, unroofing approximately two-thirds of the circumference of the entrapped vessel. Histoplasrna capsulatum could not be demonstrated in the excised tissue. Barrett’s lengthy dissertation [ll on idiopathic mediastinal fibrosis appeared in 1958. The majority of his patients suffered from superior vena caval obstruction, and he postulated that probably other vital structures of the mediastinum were not jeopardized by the fibrosing

Portal Hypertension From Idiopathic Superior Vena Caval Obstruction

An unusual combination of idiopathic superior and inferior vena caval obstruction occurred in a 15-yearold boy. Portal hypertension with ascites and associated bleeding esophageal varices developed as a result of hepatic outflow obstruction due to the occluded inferior vena cava. Surgical decompression of the portal venous system was accomplished by splenectomy and placement of a Teflon tube graft between the splenic vein and the divided pulmonary artery to the left lower lobe, since the standard methods of creating an Eck fistula were not possible in this patient. The patient has experienced marked clinical improvement during the nine months following operation.

Superior Vena Caval Canal Obstruction

(1) Sixty-one patients with superior vena caval obstruction are reviewed, of which six are secondary to benign disease. (2) Diagnosis is usually made by bronchoscopic examination or clinical evaluation. Supraclavicular or mediastinal node biopsy, and anterior thoracotomy are only employed in selected cases, because of the increased risk of hemorrhage. (3) Current preferred therapy for malignant lesions employes the initial use of chlorothiazide (Diuril) and intravenous nitrogen mustard followed by irradiation therapy. (4) In malignant lesions, the direct surgical attack to palliate the symptoms of superior vena caval obstruction is not as effective as conservative therapy and produces a higher morbidity, mortality and failure rate. The prognosis depends on the underlying disease. (5) Surgical resection has failed to extend survival in malignant cases and is not as effective as radiation alone. (6) An unusual case of a large cell undifferentiated carcinoma of the lung presenting superior vena caval obstruction with metastases to the cervical lymph nodes had survived six years following nitrogen mustard and irradiation therapy. (7) A patient with mediastinal Hodgkin's disease is alive with a patent Teflon graft between the superior vena cava and right atrium which was constructed five years ago for superior vena caval obstruction.

Superior Vena Caval Thrombosis in a 7-Year-Old Child

THE clinical manifestations of superior vena caval syndrome were first described by William Hunter in 1747. Superior vena caval obstruction occurs frequently in adults and the most common causes in these cases are bronchogenic tumors, anterior mediastinal tumors, and lymphomas. On the other hand, the syndrome of superior vena caval obstruction is relatively rare in children. Several cases in childhood have been reported however,¹the most common causes being tumors arising from the sympathetic nervous system, lymphomas, and mediastinitis and pericarditis. Thrombosis of the superior vena cava in childhood is the rarest cause of this syndrome. One previous case has been reported in the French literature by de Muralt and Menano, as cited by Valeton,²in a 5-year-old child with associated nephrosis. The diagnosis in this case was made clinically and confirmed postmortem. This case is presented as another, but rare cause of the superior vena caval syndrome.

INFERIOR VENA CAVA OBSTRUCTION: CLINICAL MANIFESTATIONS, DIAGNOSTIC METHODS, AND RELATED PROBLEMS.

Excerpt The syndrome of inferior vena caval obstruction may present with unusual and varied pathological conditions: The syndrome may resemble or be associated with such conditions as congestive he...

DILATATION OF THE LEFT SUPERIOR INTERCOSTAL VEIN IN THE PLAIN-FILM DIAGNOSIS OF CHRONIC SUPERIOR VENA CAVAL OBSTRUCTION.

In obstruction of the superior vena cava, the position of the obstruction in the cava and the rate of its development usually determine the type and extent of collateral pathways which subsequently form. Typically, a slow progression results in an extensive widely dilated collateral network. If the obstruction is caudad to the insertion of the azygos vein into the cava, the azygos vein often becomes the main collateral route between the superior and inferior vena cava with little dilatation of other collaterals. When, however, the block is cephalad to the insertion of the azygos vein, other anastomoses must be established. In this case, in addition to superficial and vertebral collaterals, blood may be shunted to the inferior vena cava via the left superior intercostal and accessory hemiazygos veins. When the obstruction is chronic, these veins may dilate to such an extent as to become visible on plain films of the chest and therefore provide a useful radiographic sign of chronic superior vena caval obstruction. The following case is reported to emphasize the importance of recognizing dilatation of the left superior intercostal vein in the diagnosis of chronic obstruction of the superior vena cava and to define the pathologic anatomy involved. In this instance postmortem as well as angiographic findings are available. Case Report The patient, a 46-year-old white woman, was first seen at the Presbyterian-University Hospital in May 1962. The chief complaints were syncope, swelling of the face, fatigue, and dyspnea on exertion. The patient had been well up until six years prior to this admission when she had been hospitalized elsewhere with the same complaints. The symptoms had begun insidiously and were progressive. Swelling of the upper extremities, head, and neck were worse on arising in the morning and gradually decreased during the day. Physical examination at that time revealed moderate edema about the face and engorgement of the neck veins. Chest films showed dilatation of the left superior intercostal vein adjacent to the aortic arch with no evidence of a mediastinal mass or pulmonary abnormalities. Venous catheterization studies disclosed obstruction of the superior vena cava at the junction of the innominate veins. A right thoracotomy revealed thrombosis of the superior vena cava over a 5-cm. segment, extending from the insertion of the azygos vein to the orifices of the innominate veins. The cava was surrounded and compressed by many caseous lymph nodes, the largest measuring 4 × 6 cm. in diameter. The thrombosed segment and the enlarged nodes were excised, and an aortic homograft was sutured in place between the right atrium and the innominate veins. The patient was given antituberculosis therapy. Following surgery she did well for six months before the gradual recurrence of her previous complaints. She was moderately incapacitated but able to work daily for the next six years with only slight progression of the symptoms.

Idiopathic fibrosis of the small bowel mesentery (primary liposclerosis)

A case of primary liposclerosis involving the small bowel mesentery has been presented. The patient complained of abdominal pain and had a low grade fever and an elevated white blood cell count. After two weeks of symptoms, laparotomy was carried out and a thick, firm plaque of tissue was found involving part of the mesentery of the small bowel. Biopsies revealed infiltration of the fatty tissue of the mesentery by macrophages, fibroblasts and some lymphocytes and there was some early fibrosis. All symptoms subsided postoperatively although no specific therapy was instituted, and the patient has had no similar trouble for three and a half years since the operation. Reports of similar involvement of the small bowel mesentery have been made by four other authors, as nearly as can be determined. There has been a number of reports of fibrosis occurring in the retroperitoneal area with resulting ureteral obstruction and in the superior mediastinum with secondary vena caval obstruction. It is possible that the process in these three areas is the same although the degree of fibrosis may differ somewhat depending on the duration. Primary liposclerosis is a descriptive term that may be applicable to the process in all three areas.

CHRONIC OBSTRUCTION OF THE SUPERIOR VENA CAVA DUE TO HISTOPLASMOSIS. A HEMODYNAMIC AND ANGIOGRAPHIC CORRELATION.

Selective angiography and indicator-dilution curves were employed to illustrate the fuctional anatomy of the collateral circulation in two patients with chronic obstruction of the superior vena cava. In both, clinical and laboratory evidence favored an etiologic diagnosis of histoplasmosis. In case 1, the transit time via the main collateral venous pathway, which comprised the left superior intercostal, accessory hemiazygos and azygos veins, was found to be a little greater than 25 seconds. In case 2, the superior vena caval obstruction was incomplete, but there was an associated severe narrowing of the right pulmonary artery. Distortion of the indicator-dilution curves provided evidence for an increased bronchopulmonary anastomotic circulation to the right lung. These observations illustrate how radiographic and hemodynamic technics may usefully be combined to assess the effects of acquired diseases of the major blood vessels.

REPLACEMENT OF SEGMENTS OF THE VENOUS SYSTEM.

This paper is a review of the continued experiences, over the past four years in this laboratory, of segmental replacement of both the superior and the inferior venae cavae in the dog. When uniform success in venous substitution is achieved experimentally, there will be adequate opportunity for clinical application in the bridging of major venous defects caused by thrombosis, radical operations for cancer, or as a sequel to injuries of the venous system. East and Muller, 1 in a review of the literature of the superior vena caval obstruction syndrome, pointed out that its treatment has been discouraging and that although the ideal replacement of the superior vena cava would be a large autogenous vein graft, these grafts are difficult to obtain. In their experimental work they found knitted Teflon grafts to be less liable to occlusion than nylon grafts. More recent reports indicate increasing success both in the experimental

PROBABLE HISTOPLASMA PERICARDITIS WITH EFFUSION. REPORT OF A CASE WITH RECURRENCE.

As Histoplasma capsulatum is capable of systemic dissemination, disease due to this agent may have protean manifestations including cardiovascular involvement. Such involvement has been reported as follows: pericardial calcification, 1-3 fibrocalcific pericarditis with constriction, 4 superior vena caval obstruction, 5 endocarditis, 6 electrocardiographic evidence of pericarditis with positive histoplasmin skin test, 7 and at least six cases of acute pericarditis with effusion. 5,8-12 The present report adds another case of acute pericarditis with effusion and recurrence probably due to H capsulatum. Report of Case A 17-year-old white man entered the University of Illinois Research and Educational Hospitals on April 8, 1960. On March 25 and March 26, I960, he had noted a mild sore throat without constitutional symptoms. At 5 am on March 27 he awakened with sharp, tight anterior chest pain accompanied by dyspnea and diaphoresis. After emergency admission to another hospital, he was treated with methylprednisolone, 4 mg t.i.d., symptomatic drugs for pain, and bed

Phlebography in Superior Vena Caval Obstruction

Phlebography in Superior Vena Caval Obstruction

Mandate for Chemotherapeutic Decompression in Superior Vena Caval Obstruction

Mandate for Chemotherapeutic Decompression in Superior Vena Caval Obstruction

The Experimental Production of Superior Vena Caval Obstruction. Trial of Different Therapy Schedules

The Experimental Production of Superior Vena Caval Obstruction. Trial of Different Therapy Schedules

Silicosis as a cause of superior vena caval obstruction

Summary A patient with superior vena caval obstruction due to external pressure of grossly enlarged silicotic glands is described. The site of the obstruction was demonstrated by phlebography, and in view of the presence of numerous collateral veins surgery was considered to be contra-indicated. The diagnosis was confirmed at post mortem.

ALLOCATION OF CARDIAC OUTPUT TO LIMB AND KIDNEY DURING HYPOTENSIVE PROCEDURES.

Cardiac output, and renal and femoral venous outflows were measured simultaneously and continuously by rotameters during hemorrhage and inferior vena caval obstruction. Acute reductions in cardiac output resulted in an immediate increased femoral and renal fraction of the cardiac output, the femoral increasing more than the renal. Further augmentation of the femoral flow fraction with reduction of the renal flow fraction was accomplished by baroreceptor area denervation or guanethidine. Following guanethidine-induced reduction of sympathetic vasoconstrictor activity of the femoral bed, the femoral flow pattern was converted to a renal flow pattern. The partition of cardiac output during acute hypotensive procedures in this experimental setting was determined by differential vasoconstrictor activity, possibly by neurohumoral agents which selectively influence certain vascular beds, and by an intrinsic property of the blood vessel wall which determines in part its response to acute reduction in flow.

THE MANDATE FOR CHEMOTHERAPEUTIC DECOMPRESSION IN SUPERIOR VENA CAVAL OBSTRUCTION.

The superior vena caval syndrome has been recognized since 1757, at which time William Hunter described a case secondary to aortic aneurysm. Individual case reports have appeared since, and in the past thirty years, larger series have been reported. Despite this two-hundred-year history, uniformity of opinion as to the best method of therapy of the syndrome is still lacking. The anatomy of the superior vena cava adequately explains the clinical picture which results from obstruction or compression of this vessel. It drains venous blood from the head and neck and the thoracic wall. Of considerable importance is the fact that the lower half of the superior vena cava is enclosed within the fibrous layer of the pericardium. Its main tributary is the azygos vein which arises at the level of the renal veins and ascends the posterior mediastinum to join the superior vena cava at the level of the second costal cartilage. Obstruction to the superior vena cava may occur at three sites: (a) above the entrance of the...

THE EXPERIMENTAL PRODUCTION OF SUPERIOR VENA CAVAL OBSTRUCTION. TRIAL OF DIFFERENT THERAPY SCHEDULES.

The large number of variables in any clinical problem demands careful organization of an investigative program to yield meaningful results. The evaluation of different therapy schedules and plans in superior vena caval obstruction patients is particularly vexing. The neoplastic etiology may range from exquisitely sensitive lymphomas to moderately responsive well differentiated bronchogenic cancers. The onset may vary from the acute and dramatic to the slow and chronic, with different degrees of collateral circulation and edema. Philosophies as to the use of irradiation alone or combined with chemotherapeutic agents run the gamut of clinical opinion, depending upon the radiotherapist, the internist, and the thoracic surgeon consulting on the case. The emergency nature of the presentation of acute caval obstruction requires a consistent and well defined approach to effect rapid relief of symptoms. The varied opinions as to proper therapy coupled with the relatively small numbers of cases led to the search for a biological model to simulate the clinical problem. After a number of attempts with different animals and tumors, the successful experimental production of the superior vena caval obstruction syndrome was accomplished. A number of different studies were designed to answer specific problems, and the results of this program have served as a guide for modifying our clinical treatment plan. Method of Study Sprague-Dawley female rats of approximately 150-gram weight were the animals used. The tumor utilized was the Rochester strain of the Murphy-Sturm lymphosarcoma, a tumor of rapid growth and radioresponsiveness. Although termed a lymphoma, its histologic characteristics simulate very anaplastic carcinomas. Donor rats with approximately seven- to ten-day old flank tumors were sacrificed. Healthy-appearing sections of tumor were morcellated in isotonic saline; a small amount of this mixture was then implanted percutaneously under the superior sternum with a No. 15 trocar (Fig. 1). Other rats from the same group underwent implantation in the flank and served as controls. Ether anesthesia was used during these procedures. The animals with mediastinal tumor implants were followed daily by supine chest radiographs and clinical observation. When the superior mediastinal shadow had widened 3 mm. or more and the clinical picture of an acute superior vena caval obstruction developed, various therapeutic measures were undertaken. Observation continued both by chest radiograph and by clinical observation. Each separate group studied included 10 to 15 animals. Without exception, the animals all survived the implant and appeared normal for at least the next forty-eight to seventy-two hours. Tumor takes were greater than 90 per cent in all groups studied. In this particular strain, spontaneous tumor regression occurred in only 1 or 2 per cent of the animals.

PHLEBOGRAPHY IN SUPERIOR VENA CAVAL OBSTRUCTION.

This paper is based on 54 cases of superior vena caval obstruction treated at the Royal Marsden Hospital, London, England, during the last three years. Phlebography was carried out to elucidate the haemodynamics in this condition and to correlate the findings with treatment and prognosis. The procedure used has varied slightly, but if sufficient contrast medium reaches the great veins and the films are good, the exact technic is of minor importance. At present our method is simple and convenient for us. Two people are concerned, each injecting 20 to 30 c.c. of 45 per cent Hypaque solution into the basilar vein on either side. Four films, at one-second intervals, are obtained, starting halfway through the injection. The vein is perfused with saline until the roentgenograms have been seen, as occasionally they may need to be repeated. The needle is connected to the syringe by polythene tubing so that considerable pressure may be applied without dislodgment. The only contradiction to phlebography is the severe illness of the patient. If necessary, the procedure can be performed later, after the patient has improved. Phlebography can give considerable information concerning the actual technic of treatment and the prognosis—information which is otherwise unobtainable. By this means a doubtful diagnosis may be confirmed or denied. Thus, in one of our early cases (Fig. 1) the patient complained of a submental swelling. It was the radiologist who suggested the diagnosis of superior vena caval obstruction; this was confirmed by phlebography. Radiotherapy relieved the condition and restored the circulation to normal. “Superior vena caval obstruction” may prove, on phlebography, to be a misnomer. The site of the obstruction may not be in the superior vena cava itself but elsewhere in the system of the great veins (Fig. 2). The extent of the obstruction —localized or widespread—may be observed phlebographically when not evidenced on plain films. Involvement of the wall of the vein by tumor may be seen as a patchy filling defect remaining constant. This may be at some distance from the site of the main obstruction (Fig. 3). Therapeutic Indications The information obtained from phlebography helps in deciding the question of anticoagulant therapy. Serial films are always essential, particularly in determining this point. The findings on phlebography may also influence the irradiation technics. It may be considered sufficient to use two large parallel opposing fields over the upper mediastinum. Most patients will respond to this treatment and they are, in any event, likely to die within six months. I feel, however, that the best possible treatment should be used in each case, and phlebography makes this possible. Treatment fields may need to be increased in size or occasionally made smaller than those normally employed. The treatment volume may need to be extended beyond the obvious limits of tumor, as it is demonstrated radiologically.

SUPERIOR VENA CAVAL SYNDROME. SLOW LOW-DOSE VERSUS RAPID HIGH-DOSE SCHEDULES.

Acute superior vena caval obstruction is one of the true emergencies encountered in radiotherapy. If untreated, the obstruction not only renders the patient helpless, but heralds death by suffocation. The main aim of any therapeutic program is to obtain rapid relief of this syndrome and avoid its recurrence. The patient with this condition is inevitably hospitalized, and consultants of different disciplines are often sought in determining the ideal management. The clinical literature unfortunately is indecisive as to the best treatment, and conflicting points of view confuse rather than clarify the issue. In view of the moribund status of the patient, there is a tendency for radiation therapy schedules to be conservative, particularly since an untoward reaction, as “radiation edema,” may tip the balance and lead to sudden death. The results of our experimental studies (p. 406) indicated that progressive edema is due to uncontrolled tumor growth rather than to irradiation (“radiation edema”). Cautious slow-dose schedules were unsuccessful, whereas high rapid-dose schedules were not only well tolerated but led to rapid relief in the majority of the animals. In the light of these findings, we have modified our clinical approach to this problem. Our initial observations are offered in this report. Diagnostic Considerations 1. Initial Study: History and physical examination should permit a working diagnosis in the emergency room. The classical physical signs are edema of the face, arms, and chest, congestion of face and conjunctivae, prominent venous collateral circulations, with aggravation of findings on recumbency. A chest film, often demonstrating a mass in the superior mediastinum, completes the first phase of examination. Because of the emergency and progressive nature of this syndrome, radiation therapy is instituted immediately and the diagnostic work-up is begun simultaneously. This is a departure from our usual policy of not accepting patients without pathologic proof of malignancy. All too often a patient becomes moribund while the house staff awaits confirmation of tests and biopsies before referral for radiotherapy. 2. Routine Confirmatory Tests: (a) Infrared photography is simple and effective in detailing collateral circulation over the chest wall and is worth following as a parameter of response to treatment. (b) Venous pressures have received much attention, but simple pressure recordings with a spinal fluid manometer in an arm vein 10 cm. below the anterior chest wall are sufficient to establish elevations, which may vary from 150 to over 350 mm. saline. It may be of interest to test both arms to determine if the innominate vein is also obstructed. Femoral vein pressures have been recorded to determine if the pressure rises with inspiration, in which circumstance the obstruction is below the entrance of the azygos vein; otherwise, it is above.