Superior Vena Cava and Innominate Vein Reconstruction in Thoracic Malignancies: Cryopreserved Graft Reconstruction

Surgical Management of Fibrosing Mediastinitis Presenting as Superior Vena Cava Syndrome

Fibrosing mediastinitis is a rare chronic inflammatory condition characterized by excessive fibrotic process in the mediastinum. Although various infectious processes are more common causes, it can also be related to several malignancies. We report a case of a 28-year-old woman with fibrosing mediastinitis related to an aggressive primary gray-zone lymphoma causing complete occlusion of the superior vena cava (SVC) and the innominate veins. She underwent several unsuccessful attempts at stenting and angioplasty. Due to worsening symptoms of SVC syndrome, she was ultimately treated with surgical reconstruction of the SVC and innominate veins using the Y-synthetic graft technique. A high degree of clinical suspicion should be maintained to diagnose fibrosing mediastinitis in onco-cardiovascular patients. With careful patient selection, review of techniques and imaging, surgical reconstruction may be a viable strategy for patients with SVC syndrome secondary to malignancy who have exhausted endovascular options.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Human aortic allograft: an excellent conduit choice for superior vena cava reconstruction

Superior vena cava (SVC) reconstruction is occasionally required in the treatment of benign and malignant conditions. We report a patient with symptomatic SVC obstruction secondary to mediastinal fibrosis successfully reconstructed with an aortic allograft.

Is it safe to divide and ligate the left innominate vein in complex cardiothoracic surgeries?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is safe to divide the left innominate vein (LIV) in aortic arch surgery to improve access. Altogether, 228 relevant papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Following LIV division, the venous drainage takes place via multiple collateral systems such as the azygous/hemiazygous, the internal mammary veins, the lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus as well as the transverse sinus. The possible complications are mainly left upper limb swelling and neurological symptoms. In one case series of 14 patients, the LIV was divided and ligated to facilitate the exposure for aortic arch surgery. More than 2-year follow-up did not reveal upper limb oedema or neurological symptoms. In two cohorts of 52 patients, the LIV was ligated prior to the superior vena cava (SVC) resection for malignancy. During the mid-term follow-up, no neurological or upper limb symptoms were reported. Although in two studies with 72 and 70 patients undergoing SVC resection it was not specified how many of them had LIV ligation, no relevant complications were reported. In a report, LIV occlusion was observed in 4 patients undergoing left internal jagular vein catheterization for haemodialysis. The reported symptom was left arm swelling with no neurological problems. In a cohort of 18 patients undergoing SVC resection for malignancy and major vein reconstruction, 7 patients underwent ligation of the LIV with no neurological symptoms. It was also concluded that reconstruction of the LIV is not consistent with favourable patency. In a case series of 10 patients with central venous obstruction, collateral pathways to conduct efficient venous drainage were mapped. We conclude that division of the LIV is safe in selected patients and operations. Patients will initially have symptoms of central vein obstruction, but these will decrease with conservative management as collaterals form.