Obstruction of the superior vena cava (SVC) produces

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1 Superior Vena Cava Obstruction: Bypass Using Spiral Vein Graft John R. Doty, MD, Jean H. Flores, RN, and Donald B. Doty, MD Department of Surgery, LDS Hospital, Salt Lake City, Utah Background. Previous midterm experience with the composite spiral saphenous vein graft to bypass the obstructed superior vena cava (SVC) has been favorable. This study looks at the long-term results in patients followed for up to 23 years. Methods. Sixteen patients aged 17 to 68 years had operation for obstruction of the SVC with SVC syndrome caused by benign disease. Eleven patients had fibrosing mediastinitis with or without caseous necrosis, 4 had thrombosis caused by a catheter or a pacemaker electrode, and 1 had spontaneous thrombosis. All operations were performed using a composite spiral vein graft constructed from the patient s own saphenous vein. Graft diameter ranged from 9.5 to 15.0 mm. Ten grafts were from the left innominate vein, and six grafts were from the right or left internal jugular vein. The grafts were placed to the right atrial in all patients except 1. Follow-up extends from 1 month to 23 years 8 months (mean follow-up, 10.9 years). Results. Fourteen of 16 grafts remain patent for up to 23 years, and all patients but 1 are free from SVC syndrome. One patient required revision of the graft for thrombosis 4 days after operation. Two grafts closed during the first year after operation: one because of recurrence of spontaneous venous thrombosis and the other because of aggressive fibrosing mediastinitis requiring operation for graft revision three times over a 12-year period prior to death. Conclusions. These data demonstrate that a spiral vein bypass graft for treatment of the obstructed SVC relieves SVC syndrome and has excellent long-term patency. (Ann Thorac Surg 1999;67:1111 6) 1999 by The Society of Thoracic Surgeons Obstruction of the superior vena cava (SVC) produces a characteristic clinical syndrome that can be severe and life threatening. Patients can experience gradual onset of symptoms from incomplete obstruction or can have acute clinical deterioration secondary to complete obstruction from thrombosis. Superior vena cava obstruction caused by benign disease typically follows a more gradual course, but can present as an aggressive fibrosing process that obliterates the large veins of the mediastinum. Operative reconstruction of the SVC using a spiral vein bypass graft was first suggested by Chiu and associates [1] in Two years later, Doty and Baker [2] reported the use of a spiral vein bypass graft in a patient with tous mediastinitis. Subsequently this operation has been used successfully for the treatment of SVC obstruction caused by benign disease and occasionally, obstruction resulting from malignant disease. Patients with type III SVC obstruction (nearly complete to complete obstruction of the SVC with reversal of azygos blood flow) benefit the most from the spiral vein bypass graft operation, particularly when there is cerebral or airway compromise [3]. Although malignancy is the cause of SVC obstruction in the majority of patients, benign etiologies are becoming increasingly more frequent in the immunosuppressed population. Mycobacterial, fungal, and opportunistic infections in these patients can be aggressive and invade the mediastinal structures [4]. Iatrogenic SVC obstruction is more commonly encountered with the increasing number of patients with transvenous pacemaker electrodes and central venous catheters for invasive monitoring, alimentation, and chemotherapy [5]. The purpose of this study is to report the long-term outcome after surgical intervention for SVC obstruction secondary to benign disease. This series of patients underwent SVC bypass with a spiral saphenous vein graft to relieve SVC obstruction with excellent late results in terms of conduit patency and relief of symptoms. Material and Methods Patient Selection Patients were considered for spiral vein bypass grafting who had obstruction of the superior cava with SVC syndrome caused by benign disease. Sixteen patients were treated over a 23-year period at The University of Iowa Hospitals and Clinics in Iowa City, IA, and at LDS Hospital in Salt Lake City, UT. The first patient underwent operation in January 1975 and the last patient, in Accepted for publication Dec 17, Address reprint requests to Dr Donald Doty, 324 Tenth Ave, Salt Lake City, UT 84103; ldddoty@ihc.com. A video clip of this procedure can be viewed on the Internet at: by The Society of Thoracic Surgeons /99/$20.00 Published by Elsevier Science Inc PII S (99)

2 1112 DOTY ET AL Ann Thorac Surg SUPERIOR VENA CAVA BYPASS 1999;67: Table 1. Patient Demographics Patient No. Age (y) Sex Cause 1 50 M Fibrosing mediastinitis with caseating 2 50 M Fibrosing mediastinitis 3 30 M Fibrosing mediastinitis with caseating 4 45 M Fibrosing mediastinitis 5 46 M SVC and innominate vein thrombosis from pacemaker electrode 6 68 M Fibrosing mediastinitis 7 38 F Spontaneous SVC thrombosis 8 25 M Fibrosing mediastinitis with caseating 9 47 F Fibrosing mediastinitis with caseating F Fibrosing mediastinitis with caseating M Fibrosing mediastinitis with caseating F SVC thrombosis from pacemaker electrode M SVC thrombosis from central venous catheter M Fibrosing mediastinitis F SVC thrombosis from central venous catheter M Fibrosing mediastinitis SVC superior vena cava. November Patient demographic data are summarized in Table 1. This represents a consecutive series of patients having elective operation for treatment of SVC syndrome caused by benign disease. There were other patients treated during this time who had SVC bypass with other conduits in the setting of trauma, malignancy, or previously excised saphenous vein. Diagnostic studies to determine the extent of SVC obstruction included bilateral arm contrast venography, computed axial tomography, Doppler ultrasound, twodimensional ultrasound, and magnetic resonance imaging. All patients had contrast venography; computed tomography or magnetic resonance imaging was employed later in the study. Diagnosis by tissue biopsy at the time of operation was performed in every instance. Eleven patients had fibrosing mediastinitis or fibrosing mediastinitis with caseous necrosis, 4 patients had thrombosis of the SVC around a pacemaker electrode or central venous catheter, and 1 patient had spontaneous thrombosis of the SVC (see Table 1). Operative Technique The operation is performed through a median sternotomy or, more recently, through a minimal incision using a partial upper-half sternotomy (Fig 1). A simultaneous incision is made in the thigh over the course of the saphenous vein. The left innominate vein is mobilized to the junction of the left internal jugular vein and the left subclavian vein. When the innominate vein and the subclavian-jugular confluence are thrombosed, it is necessary to mobilize either the left or the right internal jugular vein as the outflow point from the upper venous compartment. In this situation, the midline incision can be extended to the left or the right and the strap muscles divided to provide unrestricted passageway for the bypass conduit. The largest jugular vein can also be exposed and mobilized through a secondary cervical incision. The two incisions are joined by a tunnel beneath the sternocleidomastoid muscle. Biopsy samples of abnormal tissues surrounding the SVC are obtained. Operative procedural data are summarized in Table 2. The diameter of the innominate or jugular vein is determined, and the distance from the vein to the right atrial is measured. After mobilization of the saphenous vein, the average diameter of the vein is measured. The length of saphenous vein to be removed is determined by the ratio of the desired graft diameter to the average diameter of the saphenous vein according to the following formula: Length of saphenous vein to remove (cm) (innominate vein diameter [mm]/ saphenous vein diameter [mm average]) distance to right atrial (cm). For example, if the innominate vein is 12 mm in diameter, the saphenous vein is 4 mm in diameter, and the distance to the right atrial is 10 cm, then 30 cm of saphenous vein is required. Grafts employed in this series ranged from 9.5 to 15.0 mm in diameter. The required length of saphenous vein is removed, and the side branches are ligated. The vein is incised longi- Fig 1. Spiral vein bypass of obstructed superior vena cava by ministernotomy technique. A midline incision about 10 cm in length is made over the upper sternum. The sternum is divided in the midline to the third intercostal space where it is divided transversely. The ascending aorta and the right atrial are exposed. A simultaneous incision is made in the thigh over the greater saphenous vein.

3 Ann Thorac Surg DOTY ET AL 1999;67: SUPERIOR VENA CAVA BYPASS 1113 Table 2. Operative Procedures and Outcome After Spiral Vein Bypass Grafting Patient No. Date of Operation Spiral Vein Graft Location Length of Follow-up Outcome 1 1/10/75 Innominate vein to right atrial 23y8mo Asymptomatic; farms; graft patent on venogram 2 3/29/77 Innominate vein to right atrial 21y4mo Asymptomatic; graft patent when divided during reentry sternotomy 3 5/19/78 Innominate vein to right atrial 20y4mo Asymptomatic; runs 4.8 to 6.4 km/plays tennis 4 2/2/81 Left internal jugular vein to right atrial 17y0mo Died; three reoperations for graft occlusion 5 10/10/83 Right internal jugular vein to right 14 y 11 mo Asymptomatic atrial 6 12/27/84 Innominate vein to right atrial 13y9mo Asymptomatic; graft occluded at 4 days, reoperated, exercises regularly 7 3/31/86 Right internal jugular vein to SVC 12y5mo Occasional swelling; graft occlusion at 5 months 8 12/9/87 Innominate vein to right atrial 9y7mo Asymptomatic; runs regularly 9 6/14/88 Innominate vein to right atrial 10y3mo Asymptomatic; skis, scuba dives 10 6/26/90 Innominate vein to right atrial 7y1mo Asymptomatic 11 11/28/90 Left internal jugular vein to right 7y9mo Asymptomatic; scuba dives atrial 12 1/23/95 Left internal jugular vein to right 3y8mo Asymptomatic atrial 13 3/8/97 Innominate vein to right atrial 1y0mo Asymptomatic 14 8/12/97 Innominate vein to right atrial 1y1mo Asymptomatic; runs 5-K races, bicycles 15 7/29/98 Left internal jugular vein to right 0y2mo Asymptomatic atrial 16 11/6/98 Innominate vein to right atrial 0y1mo Asymptomatic SVC superior vena cava. tudinally through its entire length (Fig 2). A thoracostomy tube with the same diameter as the innominate or jugular vein is selected as a stent. The opened vein graft is flattened and wrapped around the stent in spiral Fig 2. An appropriate length of saphenous vein is excised. The length is based on the ratio of graft diameter to vein diameter times the desired length of the completed spiral graft (see text). Side branches are ligated. The entire length of the vein is incised longitudinally. fashion (Fig 3A), with the endothelial surface of the vein against the stent. Continuous stitches of 7-0 polypropylene suture are used to join the edges of the graft (Fig 3B), thereby forming a large conduit with the same internal diameter as the stent. There is no advantage to the use of a larger or smaller conduit. In theory, a smaller conduit could have some hemodynamic advantage by increasing flow velocity in the graft. Because the diameter of the graft is always smaller than that of the SVC, flow through the graft is always torrential because of the slightly increased venous pressure; consequently there is no need to reduce graft diameter to less than that of the inflow vein to prevent stasis in the graft. After the administration of heparin sodium, 100 U/kg intravenously, the innominate vein is ligated as close as possible to the SVC. A soft-jaw vascular clamp is applied at the internal jugular subclavian vein junction, and the innominate vein is divided, with as much length as possible retained. The distal end of the innominate vein is oversewn for secure closure (Fig 4A). The vein is cut back until all thrombus or any abnormality of the intima or vessel wall is removed. The graft is pushed slightly off the end of the stent to allow construction of an end-toend anastomosis to the innominate vein using a contin-

4 1114 DOTY ET AL Ann Thorac Surg SUPERIOR VENA CAVA BYPASS 1999;67: Fig 3. (A) The vein graft is wrapped in spiral fashion around a stent of appropriate diameter. (B) The edges of the vein are approximated by continuous suture to create a large-diameter conduit (spiral vein graft). uous 7-0 polypropylene suture (Fig 4B). If the internal jugular vein is selected as the site for anastomosis, a partial occlusion clamp is applied at the intended outflow point, and an end-to-side anastomosis is performed. The stent is then removed from the graft. When the graft must cross the thoracic inlet coming from a jugular vein anastomosis, an external stent is used to prevent compression of the graft. A short segment of an externally reinforced polytetrafluoroethylene graft somewhat larger than the spiral vein graft is placed around the vein graft as it crosses the thoracic inlet. A curved vascular clamp is placed across the right atrial, and the tip is excised. The opening in the right atrial is cleared of trabeculae to ensure unrestricted blood flow into the right atrium. The graft is anastomosed to the right atrial using a continuous 5-0 polypropylene suture (Fig 4C). The completed bypass graft must be oriented correctly and must be precisely the right length (Fig 5). Extra length serves no purpose, as the graft could kink and impede blood flow. Clinical Follow-up Patient clinical status was determined by direct interview and examination whenever possible. When this was not possible, direct telephone conversation with the patient Fig 4. (A) The left innominate vein is occluded with a soft-jaw clamp. The vein is divided, and the distal (caval) end is oversewn. (B) An end-to-end anastomosis of the spiral vein graft to the innominate vein is created. (C) The right atrial is isolated by a vascular clamp. The tip of the is excised, and all trabeculae are removed. The spiral vein graft is anastomosed to the right atrial.

5 Ann Thorac Surg DOTY ET AL 1999;67: SUPERIOR VENA CAVA BYPASS 1115 Fig 5. Completed repair. The spiral vein graft is used to bypass the obstructed superior vena cava from the innominate vein to the right atrium. and communication with the personal physician were employed. Graft patency was confirmed in some patients by computed tomographic scanning, Doppler ultrasound, or contrast venography. Patency was inferred in most cases simply by patient freedom from symptoms of SVC syndrome. In those patients in whom graft closure was documented, SVC syndrome promptly recurred. We therefore assumed that graft patency would correlate with absence of clinical symptoms. Follow-up data were available on all patients. Results Mean length of follow-up was 10.9 years (range, 1 month to 23 years 8 months). All patients survived the operation and were discharged from the hospital. Patient outcome after operation is summarized in Table 2. Three patients had graft closure within the first year after operation. One patient (patient no. 6) had thrombosis of the proximal innominate vein graft anastomosis 4 days after operation with recurrence of the face and neck swelling and other signs of SVC obstruction. Revision of the graft was performed, and the patient remains asymptomatic nearly 13 years later. Another patient (patient no. 7) had recurrence of symptoms 5 months after operation for spontaneous thrombosis of the SVC. She had not been given anticoagulants, and in retrospect, probably should have been treated with warfarin sodium after operation. Symptoms of SVC syndrome recurred, and graft closure was documented by computed tomographic scan. No further operative treatment was given. The third patient (patient no. 4) experienced graft closure 1 year after the initial operation. This patient had aggressive fibrosing mediastinitis and retroperitonitis, which subsequently obliterated both internal jugular veins, the original bypass graft, three subsequent bypass grafts, and the inferior vena cava. Superior vena cava syndrome recurred promptly each time a bypass graft occluded. At a second operation in another institution, bilateral straight saphenous vein grafts were placed from the right and left external jugular veins to the right atrium. These grafts provided partial relief of symptoms for 8 years; then they also occluded. At this point, a 10-mm polytetrafluoroethylene graft was placed from the left internal jugular vein to the right atrial. This graft occluded 3 years later, and a composite graft was constructed from the common iliac vein and inferior vena cava homograft tissue. This composite graft was placed from the left internal jugular vein near the angle of the mandible to the right atrium. The graft was enclosed in a 12-mm polytetrafluoroethylene graft. Four years after this operation, SVC syndrome recurred, and the patient died shortly thereafter. Anticoagulation with warfarin was not used after operation in any patient. All of the patients received aspirin. Fifteen (94%) of the 16 patients have had resolution of symptoms of SVC obstruction. The patient with recurrence of symptoms had graft occlusion 5 months after operation described already. Another patient had complete resolution of symptoms for more than 11 years until the graft was divided during a coronary artery bypass operation at another institution. The graft was destroyed and replaced with a straight saphenous vein graft. This patient initially had some symptoms of venous obstruction but is now asymptomatic. Comment This series of patients demonstrates excellent results with a spiral saphenous vein bypass graft for the relief of SVC obstruction caused by benign disease. It is well recognized that autologous vein produces the best results for bypass in the venous system. In addition, it is imperative that the size of the bypass conduit closely approximate that of the bypassed vein to achieve maximal flow and maintain long-term patency. The two most commonly used conduits meeting these criteria are autologous femoral vein and composite vein grafts. Bypass of the SVC using autologous femoral vein was first reported by Klassen and associates [6] in The patient s own femoral vein is generally of good caliber and length and can be removed easily. The diameter, however, cannot be adjusted to the dimensions of the inflow vein, and the length of femoral vein may not be sufficient for bypass grafts outside the thorax. The femoral vein is usually smaller than the internal jugular vein and, of course, substantially smaller than the SVC. There is also some concern that venous drainage from the leg after removal of the femoral vein can be impaired. Gladstone and coworkers [7] performed SVC bypass with autologous femoral vein in 5 patients with good relief symptoms; 2 patients experienced transient leg edema. Marshall and Kouchoukos [8] reported a case of recurrent SVC obstruction treated with an externally supported autologous femoral vein; the graft was patent on venography nearly 1 year after operation. The construction of a composite vein graft from the patient s own saphenous vein was first suggested by Benvenuto and colleagues [9], who created a paneled conduit from small sections of incised saphenous vein. This type of graft consists of parallel suture lines that run

6 1116 DOTY ET AL Ann Thorac Surg SUPERIOR VENA CAVA BYPASS 1999;67: the length of the composite graft in contrast to a spiral vein bypass graft, which is also a composite vein graft but consists of a single suture line for the length of the conduit. At any point along the length of the graft, the foreign body of the suture contacts the bloodstream at only one point on the circumference of the graft. Our series of patients documents the excellent long-term patency of such grafts, with 87.5% (14/16) of spiral vein grafts patent at a mean of 10.9 years. The initial patient had potency of the spiral vein graft documented by venography nearly 24 years after operation. Gloviczki and associates [10] reported similar excellent results with spiral vein grafts in nonmalignant SVC obstruction; bifurcated spiral vein grafts, however, were subject to early occlusion of one graft limb. Concerns about thrombosis secondary to the long suture line in a spiral vein graft appear to be unfounded, as none of the patients in our series received anticoagulation. Spiral vein bypass grafting is preferable to grafting with reversed saphenous vein, although there are reports of successful treatment of both benign and malignant SVC obstruction with single and double reversed saphenous vein grafts [11, 12]. The single patient in this series requiring double reversed saphenous vein grafting maintained patency in both grafts for 8 years, but relief of SVC syndrome was only partial during this period. Long-term patency after SVC bypass with polytetrafluoroethylene grafts has been disappointing. Gloviczki and coauthors [10] compared spiral vein bypass grafting with polytetrafluoroethylene grafting in benign SVC obstruction; the spiral vein grafts had superior patency. Nonsurgical interventions such as percutaneous transluminal angioplasty and stenting are currently inadequate to treat SVC obstruction compared with surgical treatment [13]. Although the current series of patients all had SVC obstruction resulting from benign disease, there may be a role for surgical intervention in malignancy. One of us (D.B.D.) [14] found that spiral vein bypass grafting provided excellent results for relief of SVC syndrome in 6 patients with malignant disease. No patient had recurrence of SVC obstruction, and 4 patients survived 1 year or more after operation. Smith and Brantigan [15] also reported the successful use of a spiral vein graft in a patient with adenocarcinoma of the lung; excellent palliation was achieved for the final 6 weeks of the patient s life. Anderson and Li [16] used a spiral vein graft to reconstruct the SVC after segmental resection of a compressive sarcoma. This patient was free from symptoms of SVC obstruction 17 months after operation. The spiral vein bypass graft has also been used for relief of SVC obstruction in the pediatric population, as reported by Brandt and associates [17]. In this case, the spiral vein graft was anastomosed to the left atrial without cardiopulmonary bypass in a young child with SVC syndrome after intraatrial baffle construction. Fowl and colleagues [18] discussed successful use of spiral vein grafts in heavily contaminated locations. This indication may become more common with the increase in infectious diseases in the immunosuppressed population. In summary, spiral vein bypass grafting for SVC obstruction, resulting from benign disease demonstrates excellent long-term results. Patients with nearly complete or complete obstruction will benefit from this operation, and about 90% of patients can be expected to have total resolution of symptoms relating to SVC syndrome. Most patients can be followed easily by the absence of clinical symptoms. Spiral vein bypass grafting could have an expanded role in the future treatment of SVC obstruction caused by malignant disease, in the pediatric patient, and in the immunosuppressed patient population. References 1. Chiu CJ, Terzis J, MacRae ML. Replacement of superior vena cava with the spiral composite vein graft: a versatile technique. Ann Thorac Surg 1974;17: Doty DB, Baker WH. Bypass of superior vena cava with spiral vein graft. Ann Thorac Surg 1976;22: Stanford W, Doty DB. The role of venography and surgery in the management of patients with superior vena cava obstruction. Ann Thorac Surg 1986;41: Abner A. Approach to the patient who presents with superior vena cava obstruction. Chest 1993;103:394S Escalante CP. Causes and management of superior vena cava syndrome. Oncology 1993;7: Klassen KP, Andrews NC, Curtis GH. Diagnosis and treatment of superior vena cava obstruction. Arch Surg 1951;63: Gladstone DJ, Pillai R, Paneth M, Lincoln JCR. Relief of superior vena caval syndrome with autologous femoral vein used as a bypass graft. J Thorac Cardiovasc Surg 1985;89: Marshall WG Jr, Kouchoukos NT. Management of recurrent superior vena caval syndrome with an externally supported femoral vein bypass graft. Ann Thorac Surg 1988;46: Benvenuto R, Rodman FSB, Gilmour J, Phillips AF, Callaghan JC. Composite venous graft for replacement of the superior vena cava. Arch Surg 1962;84: Gloviczki P, Pairolero PC, Toomey BJ, et al. Reconstruction of large veins for nonmalignant venous occlusive disease. J Vasc Surg 1992;16: Mitchell IM, Saunders NR, Maher O, Lennox SC, Walker DR. Surgical treatment of idiopathic mediastinal fibrosis: report of five cases. Thorax 1986;41: Larsson S, Lepore V. Technical options in reconstruction of large mediastinal veins. Surgery 1992;111: Wisselink W, Money SR, Becker MO, et al. Comparison of operative reconstruction and percutaneous balloon dilatation for central venous obstruction. Am J Surg 1993;166: Doty DB. Bypass of superior vena cava. Six year s experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease. J Thorac Cardiovasc Surg 1982;83: Smith ER, Brantigan CO. Bypass of superior vena cava obstruction using spiral vein graft. J Cardiovasc Surg (Torino) 1983;24: Anderson RP, Li W. Segmental replacement of superior vena cava with spiral vein graft. Ann Thorac Surg 1983;36: Brandt B III, Hiratzka LF, Marvin WJ Jr. Spiral vein graft: an alternative method for relief of superior vena caval obstruction following the Mustard repair. J Thorac Cardiovasc Surg 1985;89: Fowl RJ, Martin KD, Sax HC, Kempczinski RF. Use of autologous spiral vein grafts for vascular reconstruction in contaminated fields. J Vasc Surg 1988;8:442 6.