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Eur J Cardiothorac Surg 2004;26:649-651
© 2004 Elsevier Science NL

How-to-do-it

Superior vena cava reconstruction using heterologous pericardial tube after extended resection for lung cancer

^a Department of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, I-20141 Milan, Italy
^b Department of Anesthesiology, European Institute of Oncology, Via Ripamonti 435, I-20141 Milan, Italy

Received 10 March 2004; received in revised form 5 May 2004; accepted 10 May 2004.

^* Corresponding author. Tel.: +39-02-57489666; fax: +39-02-57489698
e-mail: lorenzo.spaggiari{at}ieo.it

	Abstract

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Superior vena cava (SVC) resection for lung cancer is feasible in selected patients, but the type of vessel reconstruction is still object of debate. We report a case of SVC revascularization successfully performed with heterologous ‘custom-made’ pericardial tube. This type of revascularization may improve the reconstruction of large mediastinal veins after their resection for malignancies.

Key Words: Lung cancer surgery • Surgery • Prosthesis • Venous disease • Pericardium • Bioprosthesis

	1. Introduction

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Even though superior vena cava (SVC) resection for lung cancer is still infrequently performed, to date several centers use this extended surgery in selected cases to treat advanced lung cancer, achieving interesting results in term of long-term survival (28%, 5-years survival) [1]. However, in the subgroup of patients requiring complete SVC trunk prosthetic replacement (26% of the overall population) [1,2], the choice among the different prosthesis are still debated.

To add experience on this subject, we report our latest experience concerning SVC resection for NSCLC with particular regard to the type of revascularization performed by using a custom-made bovine pericardial tube.

	2. Case report

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
From 1998, 67 patients with mediastinal great vessels involvement by lung and mediastinal tumors underwent surgical resection. SVC system resection was performed in 54 patients, and of these ones, 15 patients underwent prosthetic replacement. The last patient operated on underwent SVC replacement with a custom-made bovine pericardial tube, and he represents the object of this paper.

In August 2003, a 56-year-old man underwent induction chemotherapy with cisplatin and gemcitabine for a NSCLC cT4, (carina and SVC) cNx, cM0. After 3 cycles of chemotherapy, he was re-evaluated with total body CT scan, bone scan, and a response of 10% in tumor size was observed without signs of extra thoracic disease. Rigid broncoscopy and cervical mediastinoscopy were performed before planning extended resection. Broncoscopy confirm the invasion of the carina, while mediastinoscopy identified the infiltration of a mediastinal lymph node (R4), while the R2 ones were negative. Respiratory function tests were normal (Fev1: 120%, DLCO: 72%), and the percentage of right lung scan perfusion was 52%. Patient was monitored using a radial arterial line, a large double line in the femoral vein; a catheter insert into the internal jugular vein was used to monitor the venous pressure in the cephalic territory to maintain the arterial-venous pressure gradient during the clamping time. Finally, transesophageal echocardiography was used to monitor cardiac alteration during clamping.

The surgical approach was a large muscle sparing lateral thoracotomy. After radical lymph nodes dissection, and before lung resection, SVC trunk was completely removed and vascular continuity restored by heterologous biological prosthesis. We used a heterologous bovine pericardial patch (Shelhigh, No react^® pericardial patch, Millburn, NJ) (original size 10x20 cm) that was made tubular by a running 5/0 polypropylene suture (Fig. 1) ; the obtained biological tube was 4.5 cm long, with a diameter of about 20 mm. The length of resected SVC was about 3.5 cm (Fig. 2) . Before SVC clamping, patient received intravenous sodium heparin (0.5 mg/Kg).

View larger version (134K): [in this window] [in a new window]   Fig. 1. The heterologous bovine pericardial patch is made tubular by a running 5/0 polypropylene suture.

View larger version (129K): [in this window] [in a new window]   Fig. 2. Operative picture at the end of operation. The SVC replacement with the heterologous pericardial tube is finished; the pericardial defect is closed by using the same heterologous bovine pericardium.

Subsequently, a tracheal sleeve pneumonectomy with two running 3/0 polypropylene sutures for tracheal-bronchial anastomosis was performed. Tracheal anastomosis was covered by intercostal muscular and pericardial fat flaps, while the pericardial defect was closed by the remaining bovine pericardial patch.

The pathological analysis of the specimen identified an adenocarcinoma pT4 (SVC and carina), pN2 (3 lymph nodes, R4). The overall number of mediastinal lymph nodes resected was 27.

The hospitalization was uneventful and the full patency of the biological graft was confirmed before discharge. Low doses of low-weight heparin were administered postoperatively, until 1 month from discharge. At the last follow-up (6 months), the patient is in good state of health with a full patency of the graft assessed by phlebography and Chest CT scan, and without any anticoagulants treatment.

	3. Discussion

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Autologous pericardial patch (less frequently autologous pericardial tube) is commonly used during reconstruction of pulmonary artery [3], and sometimes to close partial vascular defects after SVC resection for lung and mediastinal malignancies [1,4,5]. Autologous pericardium is ideal in such a situations for the lower risk of infection and thrombosis with respect to synthetic prosthesis; besides, it does not require anticoagulation therapy. However, autologous pericardium is not sufficient to create long tube after complete SVC resection; thus in this last situation, SVC replacement with synthetic (PTFE) prosthesis is necessary. The disadvantages of synthetic prosthesis are the need of prolonged full anticoagulation therapy, the risk of infection (mainly after lung resection), and graft thrombosis; besides, up to now, there is a lack of knowledge regarding long-term patency of the synthetic graft after great venous vessels replacement [1,2].

It has been experimentally demonstrated that heterologous pericardial tubes showed a patency rates of 80% in an animal (ewes) model, with marked histological changes but without any influence on the patency of the graft [6]; however, up to now, no human experience are reported. The modern biological pericardial patches available today are totally detoxified reaching a full biocompatibility. The present heterologous pericardial tube, may maintain the advantages of the autologous one, but without the limits concerning the size. Our preliminary experience confirms that by using this bovine pericardial patch, a long tube can be built; this biological prosthesis does not shrink, and retain sutures better than fresh pericardium. Using the largest patch available (10x20 cm), the remaining tissue can be used to close the pericardial defect created during the extended pneumonectomy.

To the best of our knowledge, this is the first case of SVC reconstruction with an heterologous bovine custom-made pericardium tube successfully performed, and even though more experiences need before confirm its efficacy, the heterologous bovine pericardial tube should be in future took into account for the revascularization of large mediastinal veins after their resection for malignancies.

	References

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 

1. Spaggiari L., Magdeleinat P., Kondo H., Thomas P., Leon M.E., Rollet G., Regnard J.F., Tsuchiya R., Pastorino U. Results of superior vena cava resection for lung cancer. Analysis of prognostic factors. Lung Cancer 2004;44:339-346.[CrossRef][Medline]
2. Spaggiari L., Thomas P., Magdeleinat P., Kondo H., Rollet G., Regnard J.F., Tsuchiya R., Pastorino U. Superior vena cava resection with prosthetic replacement for non small cell lung cancer: long-term results of a multicentric study. Eur J Cardiothorac Surg 2002;21:1080-1086.[Abstract/Free Full Text]
3. Rendina E.A., Venuta F., De Giacomo T., Ciccone A.M., Moretti M., Ruvolo G., Coloni G.F. Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer. Ann Thorac Surg 1999;68:995-1001.[Abstract/Free Full Text]
4. Piccione W., Jr, Faber L.P., Warren W.H. Superior vena caval reconstruction using autologous pericardium. Ann Thorac Surg 1990;50:417-419.[Abstract]
5. Larsson S., Lepore V. Technical options in reconstruction of large mediastinal veins. Surgery 1992;111:311-317.[Medline]
6. Del campo C., Love J., Bowes F. Prosthetic replacement of the superior vena cava with custom-made pericardial graft: an experimental study. Can J Surg 1992;35:305-309.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lorenzo Spaggiari Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Spaggiari, L. Articles by Tosoni, A. Search for Related Content PubMed PubMed Citation Articles by Spaggiari, L. Articles by Tosoni, A. Related Collections Lung - cancer Trachea and bronchi Great vessels Pericardium