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Twelve patients who underwent graft replacement of the large mediastinal veins were reviewed. A preoperative superior vena caval (SVC) syndrome was present in seven patients. The most frequent diagnosis was a primary thoracic malignant neoplasm (10 patients). Reconstruction was performed with a pericardial tube in four patients, venae saphena magna in three patients, umbilical vein in three patients, and Dacron grafts in two patients. A temporary bypass was used in three patients. All the patients survived the operation. Eight patients died within 15 months of the surgery. Four patients are long-term survivors without signs of an SVC syndrome. Based on our experience and a review of the literature, we recommend the use of two autogenous vein grafts or a ringed polytetrafluoroethylene graft with a diameter of about one half that of the normal SVC to replace the large mediastinal veins.

From 1979 to 1989, 17 patients with obstructive superior vena cava resulted from different causes underwent various operations: azygos vein-right atrium bypass with an artificial vein (1 patient), external jugular vein-right atrium bypass (3 patients), innominate vein-right atrium bypass with the artificial veins made of autofascia (2 patients), and great saphenous veni-external jugular vein version (9 patients). Follow-up showed that version method is better than others because of good circulation and less thrombus formation.

We report a 46-year old female patient with progressive symptoms and signs of superior caval syndrome. At surgery, the caval vein with a benign intravascular paraganglioma was removed, and a venous interposition using a spiral vein graft was performed.

Microscopic angio-invasion by carcinoma of the thyroid is known. Extension into the great veins is much more uncommon. Most of the cases which have been previously described were discovered on post-mortem examination. We report the case of a 55 year-old woman who was found to have an asymptomatic small cervical goiter 6 years ago; during the last 12 months she developed superior vena cave (SVC) syndrome radiological investigation (angiography, CT scan) and surgical exploration showed a carcinoma of the thyroid with intraluminal extension of the tumor leading to thrombosis and ectasia of the SVC. Surgery was performed with resection of the whole thyroid, the SVC and the innominate veins. A double prosthetic venous by pass was then inserted between the innominate veins and right atrium. Five years after resection, the patient has no recurrence or metastasis and no clinical symptom of SVC syndrome. To our knowledge, this is only the third reported case successfully treated by surgery.

The transluminal endarterectomy catheter (TEC) system was employed as a percutaneous rotational mechanical thrombectomy device in 1-week-old thrombi in five dogs (five thrombosed polytetrafluoroethylene grafts and four thrombosed native superficial femoral arteries). Luminal patency was restored in all vessels with no angiographic evidence of significant distal embolization. The TEC catheter was also successfully used for recanalization of the superior vena cava in a patient with superior vena cava syndrome.

A 62-year-old woman with superior vena cava obstruction (SVCO) secondary to small cell lung cancer was treated with expandable wire stents prior to chemotherapy and irradiation. The treatment resulted in immediate and complete remission of the SVCO symptoms.

Metastatic colon carcinoma of the heart is a rare diagnosis, and an uncommon finding at autopsy. This report describes a patient with a huge intracavitary colonic metastasis of the right atrium causing both a superior vena cava syndrome and an obstruction of the tricuspid valve. To our knowledge, no similar case has been previously reported.

The clinical case of a female patient suffering a benign retrosternal goitre which first appeared as a superior vena cava syndrome, is presented. After confirming the diagnosis with an intrathoracic CT scan, a subtotal bilateral thyroidectomy was performed resulting in a complete remission of the clinical picture. A literature review is performed commenting on some clinical, diagnostic and therapeutical aspects.

Tumor involvement of the superior vena cava can occur either by direct extension of the primary tumor or by invasion of superior mediastinal lymph nodes. Removal of a portion of the caval wall may be required to allow adequate margins of resection. The technique described involves placement of an intraluminal shunt and resection of the involved caval wall with reconstruction using autologous pericardium.

The superior vena cava (SVC) syndrome is usually associated with advanced malignancy and has a dismal prognosis. In order to analyze the impact of newer diagnostic and therapeutic modalities, we retrospectively examined the last 45 consecutive cases of SVC syndrome treated over a 12-year period. The underlying causes were advanced lung cancer (57%), mediastinal tumors (20%), and metastatic solid malignancy (5%). Forty-two patients (93%) were treated with external beam radiotherapy and/or chemotherapy with a mean patients survival of 3 months; 11 of 42 patients (26%) were treated without histologic diagnosis. Symptoms of SVC obstruction resolved in 80% of patients who underwent radiotherapy, with a mean interval of 4 weeks. The most common cause of death was respiratory arrest. Of the three patients with benign disease, two underwent caval reconstruction with greater than 3-year patency and relief of symptoms. We conclude that (1) SVC syndrome portends a grim prognosis when associated with malignancy but usually responds to radiation or chemotherapy; (2) CT scan is the best available method to document the extent and location of involvement; and (3) patients with benign disease should be evaluated for caval reconstruction, which may produce rewarding long-term results.

Nine patients had operations for obstruction of the superior vena cava with superior vena caval syndrome caused by benign disease. Three patients had fibrosing mediastinitis, four had fibrosing mediastinitis with caseous necrosis, one had thrombosis of the superior vena cava around a pacemaker electrode, and one had spontaneous thrombosis of the superior vena cava. Patients ranged in age from 25 to 68 years. All bypass operations were performed with a composite spiral vein graft constructed from the patient's own saphenous vein, split longitudinally and wrapped around a stent in spiral fashion. The edges of the vein were sutured together to form a large conduit ranging in diameter from 9.5 to 15.0 mm. Six grafts were from the left innominate vein and three grafts were from the internal jugular vein. The grafts were placed into the right atrial appendage in all except one case, in which the graft was to the distal superior vena cava. Follow-up extends from 1 to 15 years. One patient required reoperation at 4 days for thrombosis at the innominate vein-graft anastomosis. Resection of the anastomosis and reconstruction of the graft rendered the patient symptom free. Two grafts closed during the first year after operation. One patient had advancing fibrosing mediastinitis, and a second bypass graft from the external jugular veins remain patent. Another patient had recurrence of spontaneous venous thrombosis. Thus seven of nine grafts remain patent for up to nearly 15 years and all but one patient is free of superior vena caval syndrome. These data show that bypass of the obstructed superior vena cava with a spiral vein graft relieves superior vena caval syndrome and demonstrate long-term patency of the graft.

A 31-year-old male was diagnosed to have malignant thymoma with superior vena cava occlusion. At operation, we performed extended resection of tumor and superior vena cava, and replacement with ringed PTFE graft. Histological diagnosis was nodular sclerotic type of Hodgkin's disease of thymus. He received radiation with Liniac and chemotherapy post operatively, and post operative venography revealed graft patent. He is doing well 3 years after surgery.

Uncommon case of superior vena caval obstruction secondary due to idiopathic fibrous mediastinitis was reported. A 38-year-old female was admitted in our hospital with the complaint of dyspnea and facial edema. Venography revealed occlusion of vena cava. Venous pressure showed 30 cmH2O in the external carotid vein. Mediastinal computed tomogram revealed no tumor but calcification in the anterior mediastinal fatty tissue. Therefore, with a 12 cm EPTFE, left brachiocephalic vein-right atrium bypass operation was performed. Facial edema was disappeared dramatically in early postoperative stage. She is uneventful 20 months after the operation.

Encouraged by results from our research laboratory and from recent clinical reports, we performed reconstructions of the vena cava and/or its major tributaries on 16 patients (11 males and five females). Ages ranged from 8 to 81 years (median, 38 years). Eight patients had superior vena cava syndrome (benign, six; malignant, two). Two other patients had membranous occlusion of the inferior vena cava; four had iliocaval venous thrombosis; one had excision of the iliac veins for pelvic neurilemmoma; and one had inferior vena cava injury during orthotopic liver transplantation. The superior vena cava was reconstructed with spiral saphenous vein grafts in five patients and with expanded polytetrafluoroethylene in three. One spiral saphenous vein graft and one expanded polytetrafluoroethylene graft required revision; seven of the eight grafts were patent at follow-up, but one bifurcated spiral saphenous vein graft occluded at 3 months. The inferior vena cava and its tributaries were reconstructed with expanded polytetrafluoroethylene in five patients, spiral saphenous vein graft in two, and Dacron in one. At follow-up four of the expanded polytetrafluoroethylene grafts were patent. In contrast, one of the spiral saphenous vein grafts was occluded, and results of imaging studies of the other were inconclusive. Three of the five expanded polytetrafluoroethylene grafts had a concomitant temporary arteriovenous fistula at the groin; two had documented patency at follow-up. At the present time, spiral saphenous vein graft is our first choice for superior vena cava replacement. However, expanded polytetrafluoroethylene grafts are good alternatives and in the abdomen appear to perform better than spiral saphenous vein graft. These clinical results encourage us to perform further caval grafting in selected patients.

Aggressive en-bloc resection of the superior vena cava was performed in a 50-year-old man who had superior vena caval syndrome caused by invasive thymoma. After the superior vena cava was resected, a Gore-Tex vascular graft was used to reconstruct the lower end of the right innominate vein and lower end of the superior vena cava. The patient was treated with postoperative radiotherapy to the mediastinum and has been asymptomatic for 14 months following surgery.

The paper discusses the first Soviet experience of transcatheter intravascular application of endoprosthesis into superior vena cava for compression with paratracheal lymph nodes in a patient suffering Hodgkin's disease. The patient had failed to respond to 3 cycles of combination chemotherapy and 46 Gy of radiation to the mediastinum. Application of the procedure brought the vascular lumen and blood flow to normal which led to regression of compression syndrome. The self-fixing endoprosthesis dilates and forms an interior frame for the vessel thus preventing relapse of compression in case of progression of disease.

In clinical practice SVC syndrome is an important problem, given both the nature of the disease and its fast lethal evolution. Therapy must be instituted as soon as possible because the chances of a positive result are directly related to the staging of the primary illness. Surgery, chemotherapy and high energy therapy can be used. From the literature, although controversial, the superiority of surgical therapy is clear; particularly if up-to-date vascular reconstruction techniques are employed. From March 1980 to March 1988 8 cases of SVC syndrome were observed in which the aetiology was as follows: Hodgkin's disease (2 cases); secondary catheter thrombosis (1 cases); lung carcinoma (5 cases). The 2 cases of Hodgkin's disease were treated by chemotherapy; the secondary thrombosis by open thrombectomy. In the other 5 cases an innominate vein right appendage by-pass was used (3 PTFE, 2 pericardial grafts). The results were encouraging: complete, long-term remission was observed in the Hodgkin and thrombectomy patients. A PTFE graft thrombosis occurred in 2 cases but in the other cases the by-pass is functioning well at a mean 13 months follow-up.

Idiopathic mediastinal fibrosis is a rare disease of unknown aetiology. It is a benign condition in which abnormal proliferation of fibrous tissue occurs within the mediastinum, leading to constriction and obliteration of local structures, particularly the great veins. It is a rare cause of superior vena caval obstruction (1-2%) but one that is potentially amenable to surgical palliation. The results of venous reconstruction in five patients with superior vena caval obstruction secondary to idiopathic mediastinal fibrosis are reported. Reversed autogenous saphenous vein grafts were used in two patients, woven silicone rubber prostheses in two, and bovine pericardial conduits in one patient. Useful long term results were obtained in three patients, but the bovine pericardial graft and one of the vein grafts failed within a few weeks.

Eleven patients underwent plastic operations on the superior vena cava (SVC) in its severe occlusion. The SVC syndrome was caused by malignant tumors of the right lung and mediastinum in 9 patients, lymphogranulomatosis in one patient, and by chronic fibrous mediastinitis in another patient. The SVC and its main branches were replaced by a multisegmental graft (lineal or bifurcation) of autogenous vein formed by parallel stitching together of 3-5 longitudinally cut segments of the vena saphena magna. Venous drainage was adequate and the graft remained unobstructed for a long time due to the anatomical conformity of the graft to the SVC and the equal diameters of the joined vessels. The immediate and late-term (3 to 26 months) results of plastics with a multisegmental graft or autogenous vein were good.

Surgical problems in treatment of superior vena cava syndrome are discussed by our population of 15 patients and the literature. Nine patients which suffered from caval thrombosis were managed by thrombectomy. In four cases superior vena cava was bypassed or replaced by PTFE (Gore-Tex) tubular grafts successfully. Whereas autologous vein as spiral composite graft or complete venous conduit might be preferred by reason of excellent longtime patency rates, the every time available PTFE vascular prosthesis appears to be an efficient synthetic material for replacement of superior vena cava.

Superior vena caval syndrome (SVCS) is a life-threatening medical emergency that is usually treated with high-dose irradiation. Previous attempts at surgical intervention have been disappointing. Recently, the authors have successfully treated a case of SVCS with a axillo-axillary and axillary to femoral venous bypass using an externally supported synthetic graft. This is an easy, safe, and rapid alternative for the emergent treatment of superior vena caval syndrome.

An experimental study of human umbilical vein in the use of femoral artery and jugular vein transplantation was carried out, and three patients suffering from superior vena caval obstruction were operated on by umbilical vein transplantation. The patients were followed up for 4-7 months with good results. It was found that the umbilical vein was a very good alternative in blood vessel transplantation for its lacking valves, its even caliber, its easiness to obtain, its length of up to 20 cm and a caliber of 0.3-1.0 cm, its ability to bear a pressure of up to 300 mmHg, and its causing no rejection after glutaraldehyde pretreatment. The processing and preserving of the umbilical vein were presented in detail, and its clinical implication was discussed.

One case of S.V.C.S. pas observed during surgery for cancer of lung, resection was performed and dacron graft was used. Possibilities of vascular graft in such cases, as well as peculiar situation of emergency which create the opportunity for insertion of synthetic graft were discussed.

SVC syndrome is occurred by the occlusion or stenosis of the superior vena cava secondary to malignant mediastinal tumor. Up to this report, surgical intervention has been thought to be difficult. Recently, extent of the tumor has been diagnosed exactly by CT scan, NMR, and angiography. Several cases undergoing complete resection of the tumor with the technique of vascular surgery have been reported. During the past 10 years, we have experienced 21 cases of SVC syndrome. 16 patients had operations and 5 patients had radiation or chemotherapy. The methods of operations were as follows: complete resection of the tumor 1, complete resection of the tumor and reconstruction of SVC 2, subtotal resection of the tumor and reconstruction of SVC 2, bypass of SVC only 5, extra-anatomical bypass 3. PTFE grafts were placed between right subclavian vein and SVC or left subclavian vein and right atrium. Extra-anatomical bypass were placed between jugular vein and femoral vein. PTFE bypass graft provides effective treatment for SVC obstruction with immediate and long term relief of SVC syndrome.

Fifty-four patients with renal cancer and vena cava tumour thrombus underwent radical nephrectomy and removal of the thrombus; the operative mortality rate was 9.3% (5 patients). The extent of the vena cava thrombus did not affect survival. Of 36 patients with no known pre-operative metastases and complete (29 patients) and incomplete (7 patients) removal of the vena cava tumour thrombus, the 5-year survival rate was 68 and 17%, respectively (P = 0.01). Thirteen patients (45%) who underwent complete removal of the vena cava tumour thrombus are alive and free of disease, with a mean follow-up of 51.2 months (range 4-144); three died without disease 110, 31 and 23 months after operation. The 2-year and 5-year survival rates of 18 patients with known pre-operative metastases was 37.5 and 12.5% respectively; 14 died between 1 and 27 months post-operatively (mean 11.6) of metastatic disease. Two of these 18 patients experienced long-term remission: one died of unrelated causes 151 months after operation; the other was lost to follow-up 219 months after operation, with no evidence of disease. Of 14 patients with positive regional nodes, the mean survival in those with metastases compared with those without metastases was 7.5 versus 15 months, respectively; only one patient survived at 14 months. Operative intervention in patients without metastatic disease (systemic or regional) and complete removal of the vena cava thrombus achieved a 5-year survival rate of 68%. Variables which significantly decreased survival and may be considered contraindications for operation were systemic metastasis, regional lymph node involvement and incomplete removal of the vena cava thrombus.

A case is described in which transfixation of the superior vena cava by the retained blade of a knife was the cause of acute caval obstruction. Use of a venous cannula as a stent allowed repair of the caval lacerations.

Twenty-nine reconstructions of the vena cava superior were performed: twice due to obliterating mediastinopericarditis, twice because of post-traumatic thrombosis, 4 times because of iatrogenic thrombosis, once because of an arteriovenous fistula and 24 times due to malignant tumours. In nine of the latter cases a large resection with prosthetic repair of the vena cava superior was necessary; one of these patients died and the others had no recurrence of thrombosis.

This article presents two cases about complete obstruction of major veins of upper trunk. One was a 45 year-old woman who suffered from complete obstruction of superior vena cava due to bronchogenic carcinoma. Venous bypass grafting from left innominate vein to right atrium was performed. The other was a 41 year-old man. Both of his right and left, internal and external jugular veins were completely obstructed after radical laryngectomy and radiotherapy due to hypopharyngeal carcinoma. Venous bypass grafting from cerebral transverse sinus to right atrium was performed. In both cases, general anesthesia with neurosurgical anesthetic concepts were performed with continuous blood pressure monitoring, CVP monitoring, pulse oximetry, end-tidal CO2 monitoring, blood gas analysis, urine output and EKG monitoring. The outcome was satisfactory in both cases.

Venacavography proved to be an excellent guide for the design of patient management programs. Type 1 patients with incomplete obstruction of the superior vena cava (SVC) are best managed by irradiation and chemotherapy regimens and usually do not require operation to bypass the SVC. Types II and IV patients are treated by operation when symptoms of airway obstruction or cerebral venous hypertension are present. Type III patients should be considered for SVC bypass as an initial therapeutic intervention. This group is more likely to have cerebral or airway symptoms and would benefit most from the bypass operation. In terms of operative considerations, type III patients are ideal for operation because the left brachiocephalic vein is usually available for bypass. Type IV patients may also be considered, but operation is more difficult and may require venous thrombectomy or extension of the bypass graft above the thoracic inlet to obtain head and neck decompression.

The role of vascular components in the etiology and pathogenesis of some surgical diseases of the lungs and mediastinum is appraised. It is shown that elements of vascular surgery can be introduced into thoracic surgery as a result of which operations of the organ-preserving type can be undertaken.

Magnetic resonance imaging (MRI) was used for postoperative evaluation of spiral vein grafts in three patients with fibrosing mediastinitis who had undergone bypass of the superior vena cava (SVC) for SVC syndrome. The MRI images, obtained without ECG triggering, were compared retrospectively with postoperative bilateral arm venograms. Patent grafts were identified by MRI in all patients. Significant stenoses at innominate vein-spiral vein graft anastomoses in two patients were better demonstrated by venography than by MRI. MRI shows promise as a non-invasive technique for postoperative evaluation of spiral vein bypass grafts.

Primary mediastinal seminoma is an uncommon lesion and should be included in the differential diagnosis of mediastinal tumors. Symptoms and signs may not be clear and in most cases the diagnosis is made by sternotomy or thoracotomy. Our recommendation is that patients with primary mediastinal seminoma should undergo curative resection or reductive surgery. Curative resection should be followed by radiation therapy. Chemotherapy with cisplatin-containing combinations should be reserved for patients who have metastases at the time of diagnosis.

A case of sarcoidosis is reported, which began 25 years ago. As a late complication the patient developed compression syndrome of the superior caval vein, which was caused by swelling of the lymph nodes. After surgical treatment, which was carried out by removing the regional lymph nodes and implantation of a dacron prosthesis, stenosis occurred within the proximal part of the prosthesis, which was treated by the PTA technique according to the Dotter method.

Management of superior vena caval syndrome with an autogenous vein bypass graft can be complicated by occlusion of the bypass graft. The case of a patient with recurrent superior vena caval syndrome due to occlusion of a spiraled saphenous vein graft who was managed with a femoral vein graft supported externally by a sleeve of ringed polytetrafluoroethylene is presented. A venogram demonstrated patency of the graft 11 months postoperatively, and the patient remains free from clinically apparent superior vena caval obstruction 18 months postoperatively.