SURGERY OF SUPERIOR VENA CAVA

SSUURRGGEERRYY OOFF
SSUUPPEERRIIOORR VVEENNAA
CCAAVVAA
PPrrooffeessssoorr
AAbbdduullssaallaamm YY TTaahhaa
School of Medicine/ University of Sulaimani/ Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

10/15/14 Prof. Abdulsalam Y Taha 2

ANATOMY
• The right and left innominate veins, which receive
venous blood mainly from the upper thorax, arms,
neck and head, are the major vessels returning
blood to the SVC.
• The SVC begins at the level of the first right
costal cartilage and terminates in the right atrium
at the level of the third intercostal space, and is
thus located in the superior part of the posterior
mediastinum, to the right of the aorta, and
anterior to the trachea and right main bronchus.
• The SVC is about 2 cm in diameter and 6–8 cm in
length; the last 2 cm are within the pericardial
reflection around the right atrium. The extra
pericardial part of the SVC is surrounded by
numerous lymph nodes.

AZYGOS AND HEMIAZYGOS
VEINS
• The azygos is the thoracic continuation of the
right ascending lumbar vein; it collects blood from
the right posterior intercostal veins and drains
into the posterior SVC, just above the pericardial
reflection.
• The hemiazygos vein is the continuation of the
left ascending lumbar vein; it intercepts the lower
left posterior intercostal veins, ascending on the
left side of the thoracic spine as far as the
eighth thoracic vertebral body, where it crosses
over the vertebral column to fuse with the azygos
vein.

HISTORY
• In 1757 William Hunter described a case of SVC
syndrome caused by a syphilitic aneurysm of the
ascending aorta [1].
• In 1837 William Stokes reported the first case
of SVC syndrome caused by a malignancy [2].
• In 1949 McIntire and Sykes reported the first
series of 502 cases with SVC syndrome mainly
caused by benign diseases such as syphilitic aortic
aneurysm and chronic fibrous mediastinitis from
tuberculosis, only a third of the cases were due to
primary thoracic cancers [3].
• Prior to 1949, SVC syndrome had a mainly
infectious etiology, now thoracic malignancies are
the primary cause.

HISTORY
• As regards surgery for SVC syndrome, in 1934
Carlson working on dogs found that SVC ligation
below the azygos resulted in the death of all
animals, while SVC ligation above the azygos
allowed survival, demonstrating that the azygos
system is an important collateral pathway [4].
• The first successful bypass operations for SVC
obstruction in humans were performed with
autologous femoral vein grafts by Klassen in 1951
[5] and Bricker and McAfee in 1952 [6].

HISTORY
• In 1961 Benvenuto and colleagues
constructed large caliber bypass
conduits from several segments of
saphenous vein; these were incised
longitudinally, flattened, placed over
a stent in a paneled or tiled manner
and sewn together to create the
conduit [7].

HISTORY
• In 1961 Schramel and Olinde described the
subcutaneous tunneling of a long saphenous vein
bypass conduit to the jugular vein [8].
• This technique was later adopted by Taylor and
associates (1974) [9] and Vincze et al. (1982) [10]
in seven patients with SVC obstruction due to lung
cancer.
• In 1976 Doty and Baker performed the first
successful venous bypass with a spiral saphenous
vein graft [11]. This procedure had been
developed two years previously by Chiu and
associates who performed it in a patient with SVC
obstruction secondary to granulomatous
mediastinitis [12].
• In 1986 Mitchell and colleagues described two
SVC bypasses using intact saphenous vein in
patients with mediastinal fibrosis [13].

HISTORY
• In 1987 Dartevelle et al. described
13 patients with mediastinal or lung
malignancies and SVC involvement:
they were treated by SVC resection
and reconstruction with
polytetrafluoroethylene grafts [14].

Surgery of SVC
• Resection and reconstruction of the SVC is
still considered a surgical challenge.
• However, with the appropriate indications
and surgical technique a clear benefit has
been documented in a selected group of
patients.
• The anatomy of the SVC and left
innominate vein put this venous system in a
critical area vulnerable to tumours arising
both in the lung and anterior mediastinum.

INDICATIONS
• Malignant invasion is the most frequent indication
for SVC resection and reconstruction.
• Lung cancer can involve the vessel with direct
invasion by primary tumours arising in the RUL or
by nodal metastases ( stations R2, R4 and 3).
• Anterior mediastinal tumours ( thymoma, thymic
carcinoma, germ-celltumours,etc) may involve
directly both the SVC and the left innominate
vein.
• Primary tumours of the SVC represent a rare
indication for surgery.
• Infrequent indications: saccular aneurysms,
primary malformations and traumatic
lesions( iatrogenic, blunt, or penetrating injuries).

CONTRAINDICATIONS
• The presence of SVC syndrome
related to unresectable tumours.
• A completely obstructed SVC with a
rich collateral vein circulation.
• Abnormal walls of the proximal veins
i.e., tumour involvement at the
margins.

PREOPERATIVE WORK-UP
• Total body CT scan for patients with lung cancer
or tumours of the mediastinum.
• Superior vena cavography should be performed
when SVC invasion is suspected.
• MRI: site and extent of infiltration, thrombosis
and anatomical variations of the SVC system.
• Echocardiography: to rule out right atrial
thrombosis.
• Brain CT scan for staging lung cancer and also to
rule out any brain disease that may be
exacerbated by CNS oedema during SVC clamping.
• PFTs and ABG analysis; since some patients with
RUL lung cancer invading the SVC are candidates
for standard pneumonectomy or pneumonectomy
with carinal resection.

OPERATIVE STEPS
• Surgical Approach:
Right thoracotomy in 4th or 5th intercostal
space is the standard approach for upper
lobe tumours invading the SVC. But control
of left innominate vein is difficult.
Complete median sternotomy is
recommended for tumours of anterior
mediastinum.

INTRAOPERATIVE MANAGEMENT
• Resection and reconstruction ot the SVC is
considered a major technical challenge due to the
potential detrimental effects of clamping a
patent vessel.
• Partial caval clamping or clamping a chronically
obstructed SVC is generally well tolerated; on the
other hand, occlusion of a patent SVC may
produce intracranial bleeding, brain oedema and
damage, and a potentially lethal reduction of
cardiac output.
• These complications can be avoided by careful
patient selection and intraoperative monitoring
and management.

• Double lumen ETT
• Radial art line
• Central venous line in internal JV
• 2 additional venous lines in lower limbs for
volume expansion during caval clamping.
• Foley catheter.
• ECG monitoring.
• TEE and NG tube are optional.

• Fluid imlementation and pharmological
agents: macromolecules, blood and plasma
should be used.
• Vasoconstrictive agents are used to
increase the mean art pressure.
• Diuretics are given at the end of op to
reduce oedema in cephalic region.
• Anticoagulant therapy: iv heparin 0.5
mg/kg before clamping and continued
during the immediate postop period INR=
2 to 2.5; switched to warfarin at time of
discharge.

SURGICAL STRATEGY AND
SHUNTING TECHNIQUES
• For lung cancer, the vascular step should be
always performed before airway reconstruction.
• Every effort should be attempted to reduce
clamping time as much as possible. Up to 45 to 60
minutes of complete clamping is usually tolerated
with the appropriate pharmological support.
• Intravascular or extravascular shunts may be
used to reduce the effects of vascular clamping
during resection and reconstruction of the SVC.

SURGICAL TECHNIQUE
• Tangential resection and venous plasty: in cases
with less than 30% of the SVC circumference is
involved.
• Resection is needed for larger defects.
• Replacement is achieved by a patch of autologous
or bovine pericardium. Autologous pericardium
may be fixed in 2 drops of 20% glutalaldehyde in
50 cc of saline for one minute to let it stiffen and
facilitate suturing.

SURGICAL TECHNIQUE
• SVC replacement is the most frequent type of
reconstruction. It is usually performed using a
straight non- ringed PTFE graft(18-20mm).
• An autologous or bovine pericardial tube could
also be used.
• Sometimes it may be indicated to replace only one
innominate vein according to local invasion. A
ringed PTFE should be used.
• Simultaneous revascularization of both innominate
veins is rarely required.
• Palliative bypass is extremely rare due to low
venous blood flow obtained from the axillary or
jugular veins.

COMPLICATIONS
• Anastomotic stenosis.
• Graft thrombosis.
• Graft infection.

RESULTS
• Operative mortality should be between 5% and
10%.
• The survival rate after radical resection of
mediastinal tumours invading the SVC is excellent:
60% at 5 years according to Dartevelle and
collaegues.
• Patients with lung cancer show a less favorable
prognosis: about 30% at 5 years.
• There are no long-term survivors among patients
with N2 disease.

Complete SVC substitution. Approach: lateral thoracotomy;
lung resection: superior right double sleeve lobectomy;
ringed PTFE (n. 10) prosthesis for pulmonary artery;
and ringed PTFE (size 12) prosthesis for SVC–SVC anastomosis.

Complete SVC substitution for NSCLC. Approach:
lateral thoracotomy; lung resection: tracheal sleeve.
SVC reconstructed with heterologous pericardial graft,
SVC-SVC anastomosis.

Germ cell cancer of mediastinum. Approach:
clamshell and median sternotomy; partial
resection of SVC and left innominate vein; no
reconstruction.

Left innominate vein substitution and partial SVC
resection for mediastinal tumour. Approach:
sternotomy; lung resection: left superior lobectomy
with complete antero–superior mediastinectomy and
pericardiectomy (B). Left innominate vein reconstructed
with autologous pericardium (A).

Complete SVC substitution. Approach: lateral
thoracotomy; lung resection: tracheal sleeve
pneumonectomy; ringed PTFE (size 14)
prosthesis serves to achieve SVC–SVC
anastomosis.

Complete SVC substitution. Both innominate veins
resected for mediastinal tumour; approach: sternotomy;
no lung resection; ringed PTFE (size 12) prosthesis for
anastomosis between left innominate vein and SVC.

(A–B). Complete SVC substitution. Approach:
lateral thoracotomy; lung resection: tracheal
sleeve lobectomy with neocarina (B) SVC–SVC
anastomosis with PTFE prosthesis (size 14).

Resection performed after partial SVC
clamping. SVC reconstruction by a running
polypropylene 5/0 suture.

After partial SVC resection (A) a patch of
autologous pericardium has been used to
repair the defect (B). In this case the SVC
clamping was complete.

(A–B) Partial resection of SVC by stapler
after complete control of the vessel, but
without clamping, for infiltration of azygos-caval
confluence; (C) shows reduction in the
final caliber of SVC.

Complete SVC substitution with right and left
innominate veins resection for NSCLC. Approach:
transmanubrial and lateral thoracotomy. Lung resection:
right superior lobectomy. SVC reconstructed with PTFE
(size 12) prosthesis and anastomosis between right
innominate vein and SVC.

Complete SVC substitution for NSCLC.
Approach: lateral thoracotomy; lung resection:
tracheal sleeve. SVC reconstructed with
heterologous pericardial prosthesis, SVC–SVC
anastomosis. Note the reconstruction of the
pericardial defect with the same pericardial
patch used for SVC 10/15/14 Prof. Abdulsalam Y T pahraosthesis. 34

TRAUMA TO SUPERIOR
VENA CAVA
• Iatrogenic
• Penetrating
• Blunt

SVC TRAUMA
• Superior vena cava is vulnerable to injuries
of different kinds. Most of the reported
injuries are iatrogenic; resulting from
placement of central venous catheters,
insertion of pacemakers, stenting of SVC
in SVC obstruction syndrome or placement
of a filter in the SVC to prevent showering
of emboli.
• Blunt and penetrating trauma to SVC is
rare and highly fatal

CASE REPORT
• Herein, we report a case of isolated SVC
injury by big shrapnel who unfortunately
expired in the operating theatre because
of uncontrolled hemorrhage. The case is
presented with review of up to date
medical literature. The aim is to recognize
methods of early detection and measures
of successful surgical repair.

Case History
• A 30 year old man was transferred from Kirkuk to
Sulaimania after a big terrorist explosion at
June 2007. He had an injury by shrapnel to the
right neck root. He arrived few hours after the
explosion with right-sided tube thoracostomy
draining about 1400 cc blood. On arrival, he was
pale and mildly dyspnoic. His blood pressure was
low and pulse was rapid. Air entry was diminished
on right chest. He had a wound 4 cm in size
overlying the medial half of right clavicle. There
was on other injuries. Chest radiograph revealed a
moderate-sized clotted haemothorax and a big
shell in upper chest. Lateral views were obtained
twice but were of poor quality and thus did not
reveal the shell.

• The patient was resuscitated and prepared for right thoracotomy
to drain the clotted haemothorax and stop the source of bleeding
and to deal with any intra-thoracic injuries.
• The patient was taken to operating theatre. The operating room
was very crowded that night due to other emergency operations
being performed simultaneously on other injured patients.
• The patient looked relatively stable. General anesthesia was given
via a single lumen endotracheal tube. Right thoracotomy was
chosen as that was the side of bleeding. The chest was entered
through 5th intercostals space. Large clots were found (about
1000 cc) in the pleural space posteriorly and removed completely.
The lung was healthy. There was a big and bulky shell (3 cm in
length) in the SVC just above the junction of the azygos vein with
the SVC with bleeding around it.
• Once the shell is dislodged, severe bleeding started. The bleeding
was initially controlled by manual compression while we prepared
ourselves to repair the injury. This has failed; once the hand is
released, the field is flooded with blood despite suction. A Foleys
catheter is used to tampon the bleeding temporarily. The balloon
could not be advanced enough distally because the tear was just at
the confluence of innominate veins with the SVC. Repair was not
possible with this big balloon in the tear. Surgical dissection was
done and the SVC distal to the tear was isolated and clamped but
it was not possible to do so proximally. Attempts to control the
injury with a side clamp also failed. Meanwhile, the haemodynamic
state of the patient was deteriorating. Ultimately, the patient
expired10. /15/14 Prof. Abdulsalam Y Taha 39

Alan Walsh and Howard S. Snyder. Azygos vein laceration
following a vertical deceleration injury. The Journal of
Emergency Medicine. Vol 10, pp 35-37, 1992.
• Case Report:
A 41 year old man presented with
respiratory distress and hypotension after
a 30-foot fall from a tree. Despite fluid
resuscitation, the patient expired in the
operating room. Autopsy revealed an
azygos vein laceration at the junction of
the SVC as the cause of death.

• Traumatic injuries to the SVC and azygos vein are virtually
secondary to penetrating trauma.
• They are rare following blunt chest trauma, including
vertical deceleration injury.
• Vascular injuries should be considered in any patient with a
massive haemothorax. Exsanguination may result without
aggressive resuscitation and rapid surgical intervention.
• Despite optimal care, thoracic venous injuries have a high
mortality.

Ochsner JL, Crawford ES and Debakey ME.
Injuries to the vena cava caused by external
trauma. Surgery, 1961,49: 397-405
• Ochsner reported 2 patients with
SVC rupture from crushing injuries.
• Both patients died prior to arrival in
the emergency department.

Lukas GM, Hutton JE, Lim RC and Matthewson
C. Injuries sustained from high velocity impact
with water. J Trauma 1981; 21: 612-28
• Blunt SVC rupture was found in 2
of 161 patients who jumped from
the Golden Gate Bridge.

• Unfortunately, there are
no pathognomonic signs of
azygos or SVC injuries.

• Pulmonary, hilar and intercostal
vessel injuries also present with
haemothorax.
• Subclavian, brachiocephalic and
aortic injuries must also be
considered.

• Thoracic venous injuries usually
present with signs of shock.
• The blood pressure in these vessels
is normally below systemic pressures,
but the flow is high.
• Bleeding is usually massive.

• Depending upon the exact site of
injury, bleeding into the pleural
cavity or mediastinum results.
• An injury to the SVC at its entrance
into the pericardium can produce
pericardial tamponade.

• Aggressive fluid resuscitation and
blood transfusion are important to
prevent haemodynamic collapse prior
to transporting these patients to
operating room where better lighting
and equipment are available.

• Autotransfusion is helpful
when blood loss is massive as
it uses blood drained from
the pleural cavity to restore
circulating blood volume.

• SVC injuries, resulting from blunt or penetrating
trauma will result in death before admission to
the hospital in 45% of cases.
• One third to one half of the remaining patients
will die despite aggressive resuscitation and early
surgical intervention.
• The high mortality is due to difficulty in diagnosis
and technical problems with repair.

G.M. Tiao, P.M. Griffith, J.R. Szmuszkovicz, and Hossein
Mahour. Cardiac and Great Vessel Injuries in Children
After Blunt Trauma: An Institutional Review. Journal of
Pediatric Surgery, Vol 35, No 11, 2000: pp 1656-1660
• Case
• A 9-year- old boy, was struck by an automobile that was
traveling at moderate speed. He sustained bilateral
pulmonary contusions and a right pneumothorax requiring
tube thoracostomy. The initial CXR showed a widened
mediastinum, and a chest CT was suggestive of presence of
blood around the aorta. Angiography results showed a
contained tear in the SVC. The patient was treated
nonoperatively, and he was discharged home 10 days after
admission. The patient has remained well for 6 years.

Robert J.Stallone, Roger R. Ecker, Paul C. Samson.
Management of major Acute Thoracic vascular Injuries.
The American Journal of Surgery. Vol 126, August 1974

Robert J.Stallone, Roger R. Ecker, Paul C.
Samson. Management of major Acute Thoracic
vascular Injuries. The American Journal of
Surgery. Vol 126, August 1974

R. Nair et al. management of penetrating
Cervicomedistinal Venous trauma. Eur J
Endovasc Surg 19, 65-69 (2000)

• A 25-year-old patient had an unsuccessful
resuscitative thoracotomy at which a 4 cm
wound in the SVC was clamped.
• The choice of incision was based on
established practice; median sternotomy
was done for one patient with SVC injury.

• In this study, 8 patients(26.7%) died. All of them
were shocked on admission.
• Four of the 9 patients who were admitted in
profound shock died on the operating table from
exsanguinating haemorrhage.
• In this study, there were 3 patients with SVC
injuries.
• Two patients with stab wounds of SVC died on the
operating table ( 66% mortality)
• One was ligated and one clamped only, with the
patient suffering cardiac arrest immediately
thereafter.

• One patient with SVC injury has survived.
• He had an extensive laceration of SVC at
the confluence of the brachiocephalic
veins.
• He was subjected to venorrhaphy,
narrowing the lumen of the SVC to 25% of
its normal calibre.
• Postoperatively, he developed massive
oedema of the arms, head and neck.

• Little has been written about
cervicomediastinal venous injury.
• Repair should be undertaken in stable
patients.
• In haemodynamic unstable patient or
when complex repair is needed,
ligation is the preferred option.

P.N. Symbas,E. Kaourias, D.H. Tyras, C.
R. Hatcher, J.R. Penetrating Wounds of
Great Vessels. Ann. Surg, May 1974
• 36 patients with penetrating wounds of
the great vessels treated at Grady
Memorial Hospital during a 7-year period
(1965-1972) were reviewed.
• One patient had 2 stab wounds of the SVC.
• Tangential partial occlusion of the SVC was
used.

• The true incidence of penetrating
wounds of the great vessels is not
known since many of these patients
succumb shortly after injury and
autopsy examination is not done in all
patients dying after trauma.

• Most of these patients
underwent auto-transfusion
which greatly contributed to
their successful outcome.

• In order to overcome the difficulty in
promptly procuring sufficient quantities of
blood in cases of massive haemorrahage,
auto-transfusion is used.
• This procedure has been proved to be safe
and frequently life-saving for patients
with intra-thoracic bleeding.

• For cases with cervical-thoracic
injury requiring
emergency exploration for
intra-thoracic bleeding there
is no incision which will satisfy
all needs.

• The trap door incision ( antero-lateral
thoracotomy, upper midsternotomy and
lower neck incision) has the advantage that
it can be extended to gain access to
almost all great vessel wounds but is
associated with greater morbidity to the
patient and is more time-consuming for the
surgeon.

• Wide prepping and draping of the thorax
and neck so that the thoracotomy incision
can be extended if needed, good exposure,
adequate assistance, effective suction,
sufficient blood for transfusion( or the
use ofintra-operative auto transfusion) are
essential for the success in the repair of
great vessel injury.

CONCLUSIONS
• SVC injuries are both iatrogenic and traumatic.
• Iatrogenic injuries are common and can be
diagnosed preoperatively and the proper surgical
approach chosen accordingly.
• Penetrating SVC injuries are rare. They can be
caused by stab or missile wounds.
• No case of SVC shrapnel injury is found in English
medical literature search and no case of retained
shrapnel in the SVC is reported before.
• Penetrating SVC injuries are highly lethal.
• No pathognomonic signs of SVC injury exist to
allow a preoperative diagnosis. However, great
vessel injury could be suspected with massive
haemothorax, persistent shock and a wound in
neck root.

CONCLUSIONS
• No incision is ideal and satisfactory to deal
with cervicomediastinal venous injuries in
general or SVC injury in particular.
• The high fatality of SVC injuries is due to
difficult diagnosis, difficult repair, severe
bleeding and consequences of SVC
clamping in the acute setting.
• Successful repair may be achieved with
good operating conditions, proper lighting,
effective suction, adequate assistance,
autotransfusion and good anaesthetic
management.

REFERENCES
• 1.Hunter W. The history of an aneurysm of the aorta with
some remarks on aneurysms in general. Med Observ Inq
1757;1:323.
• 2.Stokes W. A treatise on the diagnosis and treatment of
diseases of the chest. I Diseases of the lung and windpipe.
Dublin: Hodges Smith, 1837:370.
• 3.McIntire FT, Sykes EM Jr. Obstruction of the superior
vena cava: a review of the literature and report of two
personal cases. Ann Intern Med 1949;30:925–960.
• 4.Carlson HA. Obstruction of the superior vena cava: an
experimental study. Arch Surg 1934;29:669.
• 5.Klassen KP, Andrews NC, Curtis GM. Diagnosis and
treatment of superior-vena-cava obstruction. AMA Arch
Surg 1951;63:311–325.[Medline]
• 6. Bricker EM, McAfee CA. Femoral vein graft following bilateral
internal jugular vein resection. Surgery 1952;32:114–118.[Medline]

• 7. Benvenuto R, Rodman FS, Gilmour J, Phillips AF, Callaghan JC.
Composite venous graft for replacement of the superior vena cava. Arch
Surg 1962;84:570–573.[Medline]
• 8. Schramel R, Olinde HDH. A new method of bypassing the obstructed
vena cava. J Thorac Cardiovasc Surg 1961;41:375.
• 9. Taylor GA, Miller HA, Standen JR, Harrison AW. Bypassing the
obstructed superior vena cava with a subcutaneous long saphenous vein
graft. J Thorac Cardiovasc Surg 1974;68:237–240.[Medline]
• 10.Vincze K, Kulka F, Csorba L. Saphenous-jugular bypass as palliative
therapy of superior vena cava syndrome caused by bronchial carcinoma.
J Thorac Cardiovasc Surg 1982;83:272–277.
• 11.Doty DB, Baker WH. Bypass of superior vena cava with spiral vein
graft. Ann Thorac Surg 1976;22:490–493.
• 12. Chiu CJ, Terzis J, MacRae ML. Replacement of superior vena cava
with the spiral composite vein graft. A versatile technique. Ann Thorac
Surg 1974;17:555–560

• 13. IM, Saunders NR, Maher O, Lennox SC, Walker DR. Surgical
treatment of idiopathic mediastinal fibrosis: report of five
cases. Thorax 1986;41:210–214.
• 14. Dartevelle P, Chapelier A, Navajas M, Levasseur P, Rojas A,
Khalife J, Lafontaine E, Merlier M. Replacement of the superior
vena cava with polytetrafluoroethylene grafts combined with
resection of mediastinal-pulmonary malignant tumors. Report of
thirteen cases. J Thorac Cardiovasc Surg 1987;94:361–366.
• 15. Spaggiari L, Thomas P, Magdeleinat P, Kondo H, Rollet G,
Regnard JF, 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.

SURGERY OF SUPERIOR VENA CAVA

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