Surgical outcomes after superior vena cava reconstruction with expanded polytetrafluoroethylene grafts

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

OBJECTIVES

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.

METHODS

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 the 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.

RESULTS

Operative mortality was 1.7%. Cumulative incidence of all-cause mortality was not significantly different 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 the Bovine group, whereas no graft occlusion was observed in the Polytetrafluoroethylene group (P = 0.007). Although the incidence of graft occlusion was higher in the 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.

CONCLUSIONS

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

INTRODUCTION

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.

METHODS

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.

RESULTS

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 550 ml vs. 1200 ml). 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 <30 cmH 2 O in 16 patients. Bilateral reconstruction was performed if IJVP was ≥30 cmH 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).

CONCLUSIONS

Intraoperative IJVP-monitoring is a useful strategy for selection of unilateral or bilateral SVC reconstruction and improving perioperative safety in patients with mediastinal tumors.

Superior Vena Cava Resection and Reconstruction with Resection of Primary Lung Cancer and Mediastinal Tumor

The superior vena cava is a short ∼7-cm valveless vessel that brings blood from the upper half of the body to the heart but has connections to the infracardiac venous structures as well. It can become obstructed, mostly by advanced lung cancer but benign conditions account for one-fourth of cases. When possible, reconstruction can be by biological material or via ring reinforced grafts. When perfomed, replacement should be with small caliber grafts to allow for rapid flow of blood, which, with the addition of anticoagulants, reduces the risk of thrombosis. Even with advanced malignancy, treatment may confer reasonable survival.

Vascular Involvement in Thymic Epithelial Tumors: Surgical and Oncological Outcomes

BACKGROUND

The involvement of mediastinal great vessels is common in advanced stage thymic tumors, which makes their surgical resection challenging. Moreover, the impact of vascular involvement on the oncological prognosis is still unclear. The aim of this study is to investigate the surgical and oncological outcomes and the impact of vascular involvement in a population of patients operated for advanced stage thymic tumors.

METHODS

A retrospective analysis on four hundred and sixty-five patients undergoing resection for advanced stage (Masaoka III-IV) thymic tumors in a single high-volume center was performed. One hundred forty-four patients met the inclusion criteria and were eligible for the study. Patients were divided in two groups according to the presence or absence of vascular involvement.

RESULTS

the two groups did not differ for the baseline characteristics and showed comparable surgical outcomes. Vascular involvement was not associated with worse overall survival but with an increased recurrence rate (p = 0.03). Multivariable analysis demonstrated a higher risk of recurrence in patients without R0 resection (HR 0.11, 0.02-0.54, p = 0.006) and with thymic carcinoma (HR 2.27, 1.22-4.24, p = 0.01).

CONCLUSIONS

resection of thymic tumors with vascular involvement can be performed with optimal surgical results in a high volume center. From the oncological point of view, the involvement of the great vessels seems to be associated with a higher recurrence rate without affecting long-term survival.

Case Report: Superior Vena Cava Resection and Reconstruction for Invasive Thyroid Cancer: Report of Three Cases and Literature Review

Background: Thyroid cancer with massive invasion into the cervical and mediastinal great veins is extremely rare, and the surgical treatment is controversial, thus posing a great challenge for head and neck surgeons. Here, we report our successful experiences in reconstructing the superior vena cava (SVC) system to treat thyroid cancer with an extensive tumor thrombus growing intraluminally into the SVC.

Case Presentation: From September 2019 to September 2020, three patients with superior vena cava syndrome(SVCS) caused by tumor thrombus invasion from thyroid cancer were continuously included in this series. After preoperative evaluation, radical resection and reconstruction of the SVC system with expanded polytetrafluoroethylene (EPTFE) grafts were performed. In addition, bypass support from the right internal jugular vein to the right femoral vein was routinely prepared intraoperatively to prevent a rise in central venous pressure (CVP). Postoperatively, SVC-related syndrome improved immediately after the operation. Imaging examination showed good function of the reconstructed venous system. The patients recovered well with no surgical complications and remain under continuous follow-up.

Conclusions: Tumor growth into the SVC does not seem to be an absolute contraindication for surgery for thyroid carcinoma. Comprehensive treatment, including reconstruction of the SVC, is effective for relieving symptoms and preventing disease progression and is thus worth advocating. In addition, bypass support from the internal jugular vein to the femoral vein is easy to implement and can improve the safety of the operation.

Intravenous Lobular Capillary Haemangioma (Pyogenic Granuloma) of the Superior Vena Cava: Case Report and Literature Review

Introduction

Intravascular lobular capillary haemangioma is a rare benign intravascular tumour, especially in large vessels. This is the report of a case and associated literature review.

Report and literature review

This is the report of the first case of an intravenous lobular capillary haemangioma (ILCH) of the superior vena cava (SVC). A 30 year old female presented with a collateral thoraco-abdominal venous circulation. Chest computed tomography angiography, thoracic magnetic resonance imaging, and positron emission tomography revealed an intraluminal SVC tumour extending from the left brachiocephalic venous trunk to the distal third of the SVC. No pre-operative biopsy was indicated. An en bloc tumour excision was performed, followed by reconstruction of the SVC with an L shaped, ringed polytetrafluoroethylene (PTFE) prosthesis. Histopathology revealed the presence of an ILCH with free margins. A review of the literature identified 64 cases of ILCH to date, all of which underwent total resection. When reported, no recurrences were found during follow up.

Discussion

In this case, the ePTFE reconstruction of the SVC must be checked regularly for any adverse events. Although ILCH is a benign tumour with no risk of recurrence, regular surveillance is advised.

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Report of the first case of intraluminal capillary haemangioma involving the superior vena cava.

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Literature review of intraluminal capillary haemangioma.

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Successful en bloc tumour excision followed by an L shaped prosthetic repair.

Prosthetic Reconstruction of Superior Vena Cava System for Thymic Tumor: A Retrospective Analysis of 22 Cases

OBJECTIVE

This study aimed to report our experience in superior vena cava (SVC) resection and reconstruction for 22 thymic tumor patients and to make comparisons with previous related reports.

METHODS

A retrospective study on 22 patients (15 thymomas, 7 thymic cancers) who underwent tumor resection with concomitant SVC reconstruction. All the patients underwent vascular conduit reconstruction by the cross-clamping technique. The corresponding data were reviewed, including clinical presentation, operation management (surgery procedure, selection of suitable graft, strategies against SVC syndrome, etc.), postoperative cares (antithrombotic agent application, treatments on brain edema, etc.), and follow-up information.

RESULT

Two patients were myasthenic, well controlled by oral pyridostigmine. All resections were radical (R0). Ten patients received induction treatment. All the 15 thymoma patients were Masaoka stage III (type B1-B3). As for thymic cancer, six patients were Masaoka stage III and one was stage IVa. Wedge pulmonary resection was performed in three patients (two right upper lobe, one both upper lobe). Procedures included were single graft replacement in 12 patients, bilateral grafts in 9, and Y-shaped graft in 1 patient. Anticoagulation and dehydration agents were routinely applied after operation. No perioperative mortalities were observed. Major complication rate was 9.1%. The median survival time was 44.2 months (range, 4-92 months). Three- and 5-year overall survival rates were 80.8 and 44.0%, respectively. As for conduit patency, two grafts (9.1%) demonstrated evidence of occlusion during long-term follow-up, but no additional interventions were required due to no complications related.

CONCLUSION

Our study, confirming data from existing literature, showed that the prosthetic reconstruction of the SVC system is a feasible additional procedure during resection of thymic tumor infiltrating the venous mediastinal axis, minimally increasing postoperative complications in experienced hands.

Analysis of surgical treatment of Masaoka stage III-IV thymic epithelial tumors

OBJECTIVE

The purpose of this study is to elucidate the outcomes after surgical resection of Masaoka stage III-IV thymic epithelial tumors.

METHODS

We retrospectively reviewed patients with Masaoka stage III-IV thymic epithelial tumor who underwent surgical resection from January 1995 to January 2017. The clinicopathological features, surgical procedures, and postoperative outcomes were investigated.

RESULTS

Thirteen patients with thymoma and 18 patients with thymic carcinoma were assessed. The postoperative Masaoka stages were III/IVa/IVb = 8/4/1 in thymoma and III/IVa/IVb = 11/2/5 in thymic carcinoma. In patients with thymoma, the World Health Organization pathological subtypes were A/B1/B2/B3 = 2/1/4/6. We performed combined resection and reconstruction for brachiocephalic vein or superior vena cava in 3 patients with thymoma and 7 patients with thymic carcinoma. In all patients, the patency rate of the grafts was very low for the left brachiocephalic vein and well maintained for the right brachiocephalic vein. Macroscopically and pathologically complete resection was achieved in 11 and 6 patients with thymoma, respectively, and in 15 and 9 patients with thymic carcinoma, respectively. The 10-year survival rates were 85.7% in thymoma and 70.3% in thymic carcinoma. Postoperative recurrences were observed in 2 and 9 patients with thymoma and thymic carcinoma, respectively. Recurrences were observed within 5 and 10 years after surgery in 2 patients with thymoma and within 2 years in all patients with thymic carcinoma.

CONCLUSIONS

Patients with Masaoka stage III-IV thymic epithelial tumor showed relatively favorable long-term survival after surgical treatment. Therefore, aggressive surgical resection for complete resection may be a treatment option for these conditions.

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

BACKGROUND

This study aims to evaluate our results of resection and reconstruction of the superior vena cava invaded by mediastinal tumors and benign diseases.

METHODS

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.

RESULTS

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.

CONCLUSION

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.