Eur J Cardiothorac Surg 2007;32:816-817. doi:10.1016/j.ejcts.2007.07.023
Copyright © 2007, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Superior vena cava reconstruction using bovine jugular vein conduit
Wei Dong Lü,
Feng Lei Yu*,
Zhong Shi Wu
Department of Thoracic and Cardiovascular Surgery, Second Xiangya Hospital, Central South University, 410011 Hunan, People's Republic of China
Received 24 April 2007;
received in revised form 5 July 2007;
accepted 9 July 2007.
* Corresponding author. Tel.: +86 731 5295408; fax: +86 731 5362687. (Email: fengliyu66{at}yahoo.com.cn).
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Abstract
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The glutaraldehyde-treated bovine jugular vein conduit (BJVC) is a xenograft conduit initially used for right ventricular outflow tract reconstruction and has never been used for reconstruction of superior vena cava (SVC). In September 2003, a patient with SVC obstruction underwent SVC reconstruction using BJVC. He has been alive for 42 months and free from signs and symptoms of SVC obstruction except that metastasis was found in the vertebrae. The radionuclide venography showed the graft tube was patent and only slight stenosis was found in the proximal anastomosis. The initial result supports BJVC as an acceptable alternative for SVC reconstruction.
Key Words: Superior vena cava obstruction • Bovine jugular vein • Reconstruction • Invasive thymoma
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1. Introduction
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Obstruction of superior vena cava (SVC) produces a clinical syndrome that can be life-threatening. Even though surgical resection and reconstruction of SVC gave an interesting result, the choices among the different prostheses are still debated [1]. Reconstruction of SVC with bovine jugular vein conduit (BJVC) has never been reported. To add experience on the subject, we report our experience concerning SVC resection and revascularization using BJVC.
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2. Case report
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In September 2003, a 37-year-old male patient with obstruction of SVC underwent surgical therapy. Methods of diagnosis included total body computerized tomography (CT), radionuclide venography, ultrasonography and magnetic resonance imaging (MRI). Thoracic CT scan suggested a mass in the anterior mediastinum involving SVC, and radionuclide venography showed SVC was completely obstructed by the mass and the azygos vein was dilated (Fig. 1a). The patient had no histologic diagnosis before surgery.
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Fig. 1. Radionuclide venography before and after reconstruction. Part (a) shows SVC was completely obstructed by the tumor and the azygos vein was dilated. Part (b) shows BJVC was patent in 42 months after reconstruction, and slight stenosis was found in the proximal anastomosis (white arrowhead).
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Fig. 2
shows the operative procedure. A midsternal incision was made and the tumor was revealed (Fig. 2a). The upper portion of the pericardium was opened to expose the right atrium. Heparin, 1 mg/kg, was administered intravenously during the operation. A heparin-bonded shunt was placed between the left innominate vein and the right atrium as a temporary bypass and SVC was interdicted. Then the tumor and SVC involved were resected. A glutaraldehyde-treated BJVC was washed with normal saline and its valves were removed. The conduit was 17 mm in diameter and 7 cm in length. End-to-end anastomosis of the vein graft to the right innominate vein and to the end of SVC were made with 5-0 polypropylene sutures (Fig. 2b). Venous pressures were measured intraoperatively.
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Fig. 2. Operative picture before and after reconstruction of SVC with BJVC. Part (a) shows the tumor invading SVC. Part (b) shows a temporary bypass using a heparin-bonded shunt, resection of tumor, and reconstruction of SVC with BJVC.
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The patient survived the operation. Venous pressures increased in the operation but decreased after the operation with time. Although the patient temporarily appeared worse with more facial and per orbital edema, he was relieved of symptoms and signs of SVC syndrome within 48 h after the operation. Anticoagulation was performed with oral warfarin sodium(1.25 mg/day) for the first 6 months. Results of surgical pathology showed invasive thymoma and the patient underwent 60 Gy radiotherapy and CAP (CTX, ADM, DDP) chemotherapy 1-month postoperatively. Follow-up was carried out to verify patient status.
The follow-up showed no signs of recurrence of SVC obstruction. In 42 months postoperatively, the patient felt vertebrae pain and bone scan showed metastasis in the vertebrae. The radionuclide venography showed the graft tube was patent and only slight stenosis was found in the proximal anastomosis (Fig. 1b).
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3. Discussion
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Extended surgery for mediastinal and pulmonary malignancies involving SVC resulted in long-term survival in some cases. The operative procedure includes resection of primary tumor, SVC and tumor-involved tissues, and reconstruction of SVC. Prosthetic material plays a critical role for successful venous revascularization. Many biologic and synthetic materials, such as autologous vein, autologous or bovine pericardial tube and expanded polytetrafluoroethylene (ePTFE) tube had been reportedly used alone or in combination in the venous system [2–6].
Many authors agree on the superiority of autologous veins as substitutes, and autologous saphenous veins are the most often used vessels [2]; but more time is required to reconstruct a spiral vein graft and a long suture line may increase the thrombogenicity of the graft. Another alternative is an ePTFE graft, and excellent short-term and long-term results have been reported [3,4]. The advantages of an ePTFE graft are its immediate availability in length and caliber. However, the ePTFE tube presents the problems of flexion and kinking when the reconstructive conduit is long. Autologous or bovine pericardial tubes had been used in patients with mediastinal malignant carcinoma with excellent clinical results [5,6], but with a lack of external support, the pericardial tube has the potentiality to develop stenosis.
The glutaraldehyde-treated BJVC is a xenograft conduit whose wall is pliable and presents good handling characteristics. The graft retains excellent elastic property and durability. The valved BJVCs have already been applied to reconstruct the right ventricular outflow tract (RVOT) and the early and mid-term results are encouraging [7,8]. The disadvantages of BJVCs are: the need of prolonged anticoagulation therapy, the risk of infection, aneurysmal dilatation and graft thrombosis [9].
For the first time we applied BJVC to reconstruct SVC in a patient. In the operation, the valves of BJVC were removed and the azygos vein was ligated to reduce the possibility of thrombus formation. Of course, it seems to be a waste as included valves are discarded and they cannot be used for other indications. Postoperatively, the patient accepted low-dose warfarin as anticoagulation for 6 months and had a long-term patent of BJVC graft. Only slight stenosis was found in the proximal anastomosis, which did not have any effect on hemodynamic performance.
Schoof et al. [10] obtained discouraging results because of thrombosis when BJVCs were used in Fontan circulation to bypass the heart between the inferior vena cave (IVC) and the pulmonary artery. Slow and nonpulsatile flow was thought to be responsible for the thrombosis. However, no thrombosis was found in our case although reconstruction of SVC with BJVC also got a nonpulsatile flow. Both the higher pressure of SVC and ligation of the azygos vein may increase rate of blood flow, which will reduce the formation of thrombus.
To our knowledge, this is the first case of SVC reconstruction with BJVC successfully performed. The initial result supports BJVC as an acceptable alternative for SVC reconstruction.
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References
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Abstract
1. Introduction
