Results of Superior Vena Cava Reconstruction With Externally Stented-Polytetrafluoroethylene Vascular Prostheses

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1 Results of Superior Vena Cava Reconstruction With Externally Stented-Polytetrafluoroethylene Vascular Prostheses Ikenna C. Okereke, MD, Kenneth A. Kesler, MD, Karen M. Rieger, MD, Thomas J. Birdas, MD, Deming Mi, PhD, Mark W. Turrentine, MD, and John W. Brown, MD Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana Background. Resection and reconstruction of the superior vena cava (SVC) is occasionally required in the surgical treatment of intrathoracic neoplasms or symptomatic occlusion secondary to benign causes. We reviewed our institutional experience with SVC reconstruction using externally stented-polytetrafluoroethylene vascular prostheses. Methods. From 1991 to 2009, medical records of 38 patients who underwent SVC resection and reconstruction with externally stented-polytetrafluoroethylene vascular prostheses were reviewed. Indications for surgery were malignancy in 34 (89%) patients (germ cell, 13; thymoma, 10; lung cancer, 9; sarcoma, 2) and benign symptomatic occlusion in 4 (11%) patients. Results. Eighteen patients (47%) underwent right innominate vein to SVC interposition graft reconstruction, which became the favored approach during the study interval when resection of the innominate confluence was necessary. Eight patients (21%) had left innominate vein to SVC interposition grafts, earlier in the series or when the right innominate vein was unavailable. Nine patients (24%) received graft interposition of the proximal to distal SVC. The remaining 3 patients had a Y reconstruction. There were 2 perioperative mortalities. Follow-up averaged 15 months (range, 1 to 113 months), including 11 (29%) patients who died of disease. All patients demonstrated minimal to no brachiocephalic swelling at last follow-up. Twenty (53%) patients underwent imaging after an average of 24 months (range, 1 to 113 months) with only two grafts demonstrating complete occlusion. Conclusions. Although several SVC reconstructive techniques have been described, externally stented-polytetrafluoroethylene vascular prostheses are readily available for off-the-shelf use. In our experience, patency rates are high, and patients who do demonstrate graft thrombosis have minimal to no symptoms. (Ann Thorac Surg 2010;90:383 7) 2010 by The Society of Thoracic Surgeons Benign or malignant disease involving the superior vena cava (SVC) may cause significant symptoms of venous obstruction, manifest by facial swelling, dyspnea, and stridor [1 3]. Resection and reconstruction of the SVC presents a surgically challenging situation. Various strategies to reconstruct the SVC have been investigated previously [4 7]. During the past two decades when SVC reconstruction has been necessary, our institution has consistently used externally stented-polytetrafluoroethylene (ES-PTFE; Gore-Tex Corp, Newark, DE) vascular prostheses. In this study we reviewed this experience with SVC resection and reconstruction using ES-PTFE. Material and Methods From January 1991 through May 2009, 38 patients underwent resection and reconstruction of the SVC with ES- Accepted for publication April 2, Presented at the Poster Session of the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25 27, Address correspondence to Dr Okereke, Department of Cardiothoracic Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 215, Indianapolis, IN 46204; iokereke@iupui.edu. PTFE graft interposition. After approval from the institutional review board and waiver of need for patient consent, medical records of these patients were retrospectively reviewed. Preoperative use of chemotherapy or radiation therapy, based on a multidisciplinary approach, was noted. Demographics, pathologic results, surgical data, and postoperative graft patency were recorded. Graft size and method of SVC reconstruction were also recorded. Postoperative graft patency was determined by patient follow-up and computerized tomography (CT) scan. Social Security Death Index and institutional records were used to determine survival status in all patients. Kaplan-Meier analysis was used to calculate overall survival. Results Patient Demographics Mean patient age was years. Seventy-seven percent of patients were male. The indications for surgery were primary mediastinal non seminomatous germ cell tumor in 34% (13 of 38 patients), thymoma in 26% (10 of 38 patients), non small cell lung cancer (NSCLC) in 2010 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 384 OKEREKE ET AL Ann Thorac Surg SVC RECONSTRUCTION 2010;90: % (9 of 38 patients), histoplasmosis in 11% (4 of 38 patients), and sarcoma in 5% (2 of 38 patients). Preoperative chemotherapy or radiation therapy was administered to 72% of the patients. Decisions to treat before surgery were based on tumor pathology, stage, and CT characteristics. All patients with primary mediastinal non seminomatous germ cell tumor received chemotherapy before surgery. Ninety percent of patients with thymoma (9 of 10 patients) received neoadjuvant chemotherapy or radiation treatment. Only 44% (4 of 9 patients) of the NSCLC patients received neoadjuvant treatment. All 4 patients who had SVC reconstruction for benign disease were severely affected by SVC syndrome preoperatively. These patients were evaluated by the interventional radiology department and deemed to be nonstentable owing to heavy calcific obstruction. In contrast, only 2 of the patients with neoplasms manifested SVC syndrome at the time of surgery. One patient with NSCLC who presented with severe symptoms required urgent surgery. Surgery Airway management was performed using a doublelumen endotracheal tube to allow for selective lung ventilation in all cases. All patients had central venous catheters placed in the femoral vein after anesthetic induction and removed 48 to 72 hours postoperatively. After a standard skin prep was applied, an antimicrobial incision drape (3M Heath Care, St. Paul, MN) was placed. Prophylactic intravenous cephalosporin antibiotics were administered after anesthetic induction and for 48 hours after surgery. The surgical approach was chosen to optimize dissection around critical structures anticipated to be encountered at the time of surgery, including the great veins. Sternotomy was used in 27 cases (71%), followed by a thoracotomy in 7 cases (18%), a clamshell incision in 3 cases (8%), and a trap-door incision in 1 case (3%). Although the surgical indications varied, the conduct of these procedures was consistent. Once the initial dissection of the tumor or benign surrounding tissue was performed and the SVC could be accessed, both innominate veins and the SVC, just proximal to the SVC right atrial junction, were isolated. The azygous vein was typically ligated. In cases in which SVC resection was required for malignancy, the right phrenic nerve was identified and preserved when oncologically feasible before venous clamping. The phrenic nerve was carefully mobilized and preserved in all benign cases. The period of SVC clamping typically lasted no longer than 30 minutes for establishment of both the proximal and distal anastomoses. Most patients tolerated clamping of the SVC without hemodynamic compromise. Those patients who did experience hemodynamic compromise were easily stabilized with fluid administration and intravenous vasopressors. Two patients required cardiopulmonary bypass to facilitate resection. Both of these patients had a tumor that extended onto the heart and required partial resection of the right atrium to achieve complete resection. Pulmonary resection, ranging from wedge resection to pneumonectomy, was required in 22 of 38 (58%) patients. After the SVC was resected, reconstruction was performed in a variety of ways. Table 1 displays the various methods of SVC reconstruction for each disease process. Methods of reconstruction included a graft from the right innominate vein to the SVC (n 18; 42%), from the distal SVC to the proximal SVC (n 9; 24%), from the left innominate vein to the SVC (n 8; 21%), and a Y graft from each innominate vein to the SVC (n 3; 8%). The size of the ES-PTFE graft ranged from 8 to 19 mm. The most common size used was 16 mm (n 17; 45%). When an isolated innominate vein to SVC reconstruction was performed, the ES-PTFE graft diameter ranged from 8 to 16 mm. When the graft went from the proximal SVC to the distal SVC, the ES-PTFE graft diameter ranged from 13 to 19 mm. During the study period, the favored method of reconstruction became the right innominate vein to the proximal SVC, with ligation of the left innominate vein when resection of the innominate confluence was necessary. When the method of reconstruction was from the left innominate vein to the SVC, the sternal retractor was closed partially to estimate the final length and angle of the graft more closely. The proximal-toflow anastomosis was typically established first using a running 5-0 PTFE (Gore-Tex Corp), followed by a distalto-flow anastomosis. Vascular clamps remained in place until the second anastomosis was complete. The distal anastomosis was left untied briefly to remove air from the prosthetic graft after the proximal clamp was removed. Table 1. Methods of Reconstruction for Each Disease Process Right Innominate SVC Left Innominate SVC Proximal SVC Distal SVC Bilateral Innominate SVC (Y Graft) NSGCT 8/13 (62%) 2/13 (15%) 2/13 (15%) 1/13 (8%) Thymoma 5/10 (50%) 2/10 (20%) 1/10 (10%) 2/10 (20%) NSCLC 3/9 (33%) 3/9 (33%) 3/9 (33%) 0 Histoplasmosis 2/4 (50%) 1/4 (25%) 1/4 (25%) 0 Sarcoma 0 0 2/2 (100%) 0 Patent graft at last CT follow-up a 9/10 (90%) 4/4 (100%) 3/4 (75%) 2/2 (100%) a Includes only patients who had postoperative CT scan. CT computed tomography; NSCLC non small cell lung cancer; NSGCT non seminomatous germ cell tumor; SVC superior vena cava.

3 Ann Thorac Surg OKEREKE ET AL 2010;90:383 7 SVC RECONSTRUCTION The distal clamp was quickly removed thereafter, and the suture of the distal-to-flow anastomosis was tied. Clamps were not placed on the ES-PTFE grafts at any time. Median estimated blood loss was 700 ml (range, 150 to 2,500 ml). 385 Postoperative Mortality and Morbidity Median length of stay was 9 days. Operative mortality occurred in 3 patients (8%). Two of the operative deaths were a result of respiratory failure, and 1 of the operative deaths was secondary to sepsis. One patient who had undergone a wide resection of the pericardium with the tumor experienced cardiac herniation on postoperative day 1. The patient was returned to the operating room for pericardial reconstruction and had an uneventful postoperative course thereafter. Six of the 38 patients (16%) required a tracheostomy to facilitate ventilation weaning. Temporary recurrent laryngeal dysfunction occurred in 1 patient (3%). Pathology All patients who underwent operations for neoplasms achieved complete resection, with negative margins. Mean tumor size was 8 cm (range, 1 to 20 cm). All 9 patients with NSCLC were considered T4 neoplasms owing to SVC involvement. Six patients had no positive nodes, 2 patients had positive mediastinal nodes, and 1 patient had only hilar nodes positive. Squamous cell cancer was seen in 4 patients, adenocarcinoma in 3 patients, and other pathologic diagnosis in 2 patients. Of the 13 patients with primary mediastinal non seminomatous germ cell tumor, postchemotherapy pathologic diagnosis included yolk sac tumor (n 7), complete necrosis (n 3), teratoma (n 2), and adenocarcinoma (n 1). Table 2 provides staging and cellular pathologic classification for the 10 thymoma patients. Patency and Follow-Up Considering survivors and patients who died of disease, the overall mean length of follow-up was 15 months. Twenty (53%) patients underwent CT imaging for cancer surveillance, after an average of 24 months (range, 1 to 113 months). Only two grafts demonstrated evidence of occlusion. Figure 1 shows a postoperative CT scan that demonstrates a patent ES-PTFE graft from the right innominate vein to the SVC, with ligation of the left Table 2. Thymoma Staging and Cellular Classification Classification/Staging World Health Organization Classification A B C Total Masaoka staging I II III IV Total Fig 1. Computed tomography scan displaying patency of externally stented-polytetrafluoroethylene graft from the right innominate vein to superior vena cava with ligation of the left innominate vein. Note slight oversizing of the externally stented-polytetrafluoroethylene graft compared with the right innominate vein. innominate vein. This CT scan was obtained 2 months postoperatively. None of the 38 patients, including the patients who had radiographic evidence of graft occlusion, had significant symptoms of SVC obstruction at last follow-up. No patients required reoperation for graft replacement. There were no patients who were treated for prosthetic graft infection. Postoperatively patients undergoing dental or other such procedures with anticipated transient bacteremia were not recommended to take antibiotic prophylaxis. Survival Of the operative survivors, 77% of patients were alive at follow-up. Patients who had NSCLC as the indication for surgery had a significantly worse survival compared with patients who had other indications (Fig 2; p 0.014). Eight of the 9 patients in the series with NSCLC had died, with a mean length of survival after surgery of 12.5 months. There were no other factors significantly associated with survival in the series. One of the 2 sarcoma patients died perioperatively, whereas the other patient was alive and well at last follow-up, 21 months after surgical resection. Comment Although resection and reconstruction of the SVC is technically challenging, it can be performed successfully in select patients [8, 9]. Involvement of the SVC by tumor, as such, should not be considered a contraindication to surgical resection. In our series we reviewed only those patients who had undergone complete resection and prosthetic graft reconstruction. We excluded from our review 33 patients who had simply undergone partial SVC resection with patch angioplasty. Although previous literature has shown that complete resection versus patch

4 386 OKEREKE ET AL Ann Thorac Surg SVC RECONSTRUCTION 2010;90:383 7 Fig 2. Overall survival by disease process in operative survivors. Patients at risk are shown at 6-month intervals. (NSCLC non small cell lung cancer; NSGCT non seminomatous germ cell tumor.) angioplasty does not seem to increase perioperative complication rate significantly [10], we speculate that complete resection may have a higher risk of postoperative thrombosis. There are several techniques of SVC resection that have been described in the literature. Other prosthetic materials, such as Dacron (polyethylene terephthalate fiber) and glutaraldehyde-preserved porcine pericardium, and autologous tissue, such as saphenous vein spiral grafts or pericardium, can be used to replace the SVC. When compared with unsupported PTFE and pericardium, experimental studies showed longer patency rates and less inflammation than with ES-PTFE [11, 12]. Similarly, long-term patency may be improved with ES-PTFE versus autologous vein [13]. Dartevelle and colleagues [14] reported a series of 13 patients who underwent ES-PTFE reconstruction of the SVC with 92% patency. All series, including the present, are relatively small, however, and statistical comparisons among the various techniques are difficult. There has been controversy regarding the role of anticoagulation after venous reconstruction [5, 15, 16]. The first 3 patients in the series were placed on postoperative systemic warfarin anticoagulation. This practice was based on concerns that a prosthetic graft in a low pressure low flow vascular system such as the SVC would be more prone to thrombosis. Because of a bleeding complication early in the study period, however, we subsequently elected not to anticoagulate patients, avoiding the risks, costs, and inconvenience. We instead opted for daily aspirin only. This practice did not appear to lead to an excessive thrombosis rate. Only 2 patients in our series experienced documented graft thrombosis, and neither of these patients exhibited significant symptomatology of SVC syndrome. We speculate that graft occlusion in these cases occurred slowly with time, which allowed collateralization and prevented symptoms. Our current practice is not to anticoagulate patients with warfarin after SVC reconstruction, and we believe that our long-term patency rates support this strategy. We speculate that the factors that will prevent thrombosis of the prosthetic graft after SVC reconstruction are mainly technical. As such, it is paramount to avoid any kinking of the graft. Early in the series we thought that creating a Y graft from each innominate vein to the SVC would allow for better brachiocephalic venous drainage, and therefore improved symptomatic relief. We observed, however, that mediastinal tumors requiring unilateral innominate vein resection without reconstruction resulted in only minimal and temporary upper extremity edema. This observation, along with the theoretical advantage and flow mechanics of unilateral right innominate vein SVC reconstruction, led us to abandon the more cumbersome Y graft reconstruction technique. We therefore elected to perform graft reconstruction from only one innominate vein, preferably the right, to the SVC when the innominate vein confluence was involved with the disease process. Reconstruction of only one innominate vein ostensibly results in higher graft flow. Although it is technically more difficult to perform a right innominate vein to graft anastomosis than a left innominate vein to graft anastomosis, this approach results in minimal graft angulation and direct downward blood flow aided by gravity. When the right innominate vein is not available, left innominate to SVC reconstruction is necessary. Closing the sternal retractor before creation of the second anastomosis allows for a more appropriate determination of graft length. Otherwise, left innominate to SVC grafts may be too long and kink after sternal closure. We believe that one final important technical note is to size the graft to the diameter of the SVC, and then cheat when performing the graft to innominate vein anastomosis, with more suture advancement on the graft relative to the innominate vein. Selecting a graft diameter equal to the SVC diameter allows for an appropriate diameter for flow requirements. We experienced only two episodes of documented graft occlusion in the entire series. One patient with graft occlusion had an SVC SVC graft, whereas the other patient had a right innominate SVC graft. Because the series is small and the rate of occlusive events was low, we were unable to make significant associations between the method of SVC reconstruction and graft patency. Furthermore, as the patients with documented graft occlusion manifested little to no symptomatology, it is possible that there were additional prosthetic graft occlusions in the subset of patients who did not undergo postoperative radiographic imaging. Advantages to our study include that it was a consecutive, single-institution series and that ES-PTFE graft interposition was the only type of graft used in the series. Indications for SVC resection and reconstruction included both benign and malignant disease processes in our series. As expected, patients with benign causes and malignancies with better prognoses demonstrated improved long-term survival versus patients with NSCLC. Although long-term survival was limited in NSCLC pa-

5 Ann Thorac Surg OKEREKE ET AL 2010;90:383 7 SVC RECONSTRUCTION tients in our series, patients did benefit from an improved quality of life after surgery. Furthermore, we speculate there is no significant difference in mean survival between the NSCLC patients in our series compared with previously published survival for stage IIIB NSCLC after surgery, given the small number of patients in our series [17]. Nodal status did not appear to impact long-term survival in our series, but again we acknowledge that the overall number of patients with NSCLC is relatively small to determine the effect of nodal status on survival after reconstruction of the SVC [18, 19]. The ES-PTFE grafts are known for excellent long-term durability and are readily available as off-the-shelf prostheses. Reconstruction of the SVC, using ES-PTFE vascular prostheses in conjunction with resection of benign or malignant disease, can be performed with low risks, symptomatic relief of SVC syndrome, and good longterm patency without anticoagulation. This study also confirms that most patients with both benign and malignant disease requiring SVC resection demonstrate longterm survival, justifying an aggressive surgical approach. References 1. Chen JC, Bongard F, Klein SR. A contemporary perspective on superior vena cava syndrome. Am J Surg 1990;160: Nunnelee JD. Superior vena cava syndrome. J Vasc Nurs 2007;25: Wan JF. Superior vena cava syndrome. Emerg Med Clin North Am 2009;27: Chiu CJ, Terzia J, MacRae ML. Replacement of the superior vena cava with the spiral composite vein graft: a versatile technique. Ann Thorac Surg 1974;17: Dartevelle PG, Chapelier AR, Pastorino U, et al. Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal pulmonary malignant tumors. J Thoracic Cardiovascular Surg 1991;102: Dartevelle P, Macchiarini P, Chapelier A. Technique of superior vena cava resection and reconstruction. Chest Surg Clin N Am 1995;5: Gloviczki P, Pairolero PC, Toomey BJ, et al. Reconstruction of large veins for nonmalignant venous occlusive disease. J Vasc Surg 1992;16: Kaiser LR. Surgical treatment of thymic epithelial neoplasms. Hematol Oncol Clin North Am 2008;22: Kesler KA. Technique of mediastinal germ cell tumor resection. Op Tech Thorac Cardiovasc Surg 2009;14: Leo F, Bellini R, Conti B, Delledonne V, Tavecchio L, Pastorino U. Superior vena cava resection in thoracic malignancies: does prosthetic replacement pose a higher risk? Eur J Cardiothorac Surg 2010;37: Fiore AC, Brown JW, Cromartie R, et al. Prosthetic replacement for the thoracic vena cava: an experimental study. J Thorac Cardiovasc Surg 1982;84: Robison RJ, Peigh PS, Fiore AC, et al. Venous prostheses: improved patency with external stents. J Surg Res 1984;36: Larsson S, Lepore V. Technical options in reconstruction of large mediastinal veins. Surgery 1992;111: Dartevelle P, Chapelier A, Navajas M, et al. Replacement of the superior vena cava with polytetrafluoroethylene grafts combined with resection of mediastinal-pulmonary malignant tumors. Report of thirteen cases. Thorac Cardiovasc Surg 1987;94: Spaggiari L, Leo F, Veronesi G, et al. Superior vena cava resection for lung and mediastinal malignancies: a singlecenter experience with 70 cases. Ann Thorac Surg 2007;83: Shintani Y, Ohta M, Minami M, et al. Long-term graft patency after replacement of the brachiocephalic veins combined with resection of mediastinal tumors. J Thorac Cardiovasc Surg 2005;129: Jett J, Schild S, Keith R, Kesler K; American College of Chest Physicians. Treatment of non-small cell lung cancer, stage IIIB: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132(Suppl):266S 76S. 18. Pitz CM, Riviere AB, van Swieten HA, et al. Results of surgical treatment of T4 non-small cell lung cancer. Eur J Cardiothorac Surg 2003;24: Thomas P, Magnan PE, Moulin G, et al. Extended operation for lung cancer invading the superior vena cava. Eur J Cardiothorac Surg 1994;8: