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Spiral saphenous vein graft in the management of superior vena cava syndrome:
A Case Report
(Portuguese PDF version)

Ricardo César Rocha Moreira¹, Marcio Miyamotto², Graciliano José França³

1. PhD in Clinical Surgery, Universidade Federal do Paraná. Chief of Prof. Dr. Elias Abrão Division of Vascular Surgery, Curitiba, PR, Brazil.
2. Vascular and Endovascular Surgeon, Prof. Dr. Elias Abrão Division of Vascular Surgery, Curitiba, PR, Brazil.
3. Vascular Echographist, Hospital Nossa Senhora das Graças and Clínica Ecodoppler Colorido, Curitiba, PR, Brazil.

Correspondence:
Rua Pedro Muraro 50/casa 24
CEP 82030-620 - Curitiba - PR
Brazil
Tel.: +55 (41) 244.8787
Fax: (41) 335.3233
E-mail: ina@onda.com.br

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ABSTRACT

Superior vena cava syndrome is a rare condition that is usually caused by malignancy, especially bronchogenic carcinoma. Idiopathic fibrosing mediastinitis rarely leads to superior vena cava syndrome. The authors report the case of a patient with superior vena cava syndrome caused by idiopathic fibrosing mediastinitis. The patient had been previously treated with internal jugular-right atrial bypass surgery with polytetrafluoroethylene, which occluded four years later. A new internal jugular-right atrial bypass using a spiral saphenous vein graft was then performed. After 15 years of follow-up, the patient is asymptomatic and the spiral graft is patent by duplex scan.

Key words: superior vena cava syndrome, fibrosis, venous thrombosis.
Palavras-chave: síndrome da veia cava superior, fibrose mediastinal, e trombose venosa.

J Vasc Br 2003;2(4):329-32

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Superior vena cava syndrome (SVCS) was first described by William Hunter in 1757. Until 1990, more than 2,000 cases had been reported.¹ This condition is caused by malignant tumors in 85% of the patients, especially bronchogenic carcinoma. Currently, central venous catheterizing for prolonged access and pacemaker placement have become significant causes of this syndrome.² Inflammatory diseases of the mediastinum can rarely lead to fibrosing mediastinitis.^3,4. The authors present a case study of a patient with SVCS caused by idiopathic fibrosing mediastinitis treated with a spiral saphenous vein graft.

CASE REPORT

A 27 year-old male was admitted in our Service. He complained of headaches and edema of the face, torso and upper limbs. At physical examination, he presented with edema and extensive collateral circulation in the torso and upper limbs. The chest x-ray showed a right paramediastinal mass. Venography through bilateral puncture of the upper limb showed superior vena cava occlusion and collateral venous network. The patient underwent a median sternotomy. A whitish and fibrotic mediastinal mass was found to be compressing the superior vena cava. The intraoperative pathologic examination was inconclusive for malignancy. A biopsy and a bypass from the right internal jugular vein to the right atrium with polytetrafluoroethylene (PTFE) were performed. The patient reported complete relief of symptoms in the immediate postoperative period and was discharged four days after the operation. The result of the pathological examinations evidenced a fibrosing mediastinitis with an undetermined etiology (idiopathic). Four years later, the patient presented recurrence of symptoms and PTFE graft occlusion. Investigation for tuberculosis and systemic mycoses provided negative results. The patient underwent a new right internal jugular vein bypass in the right atrium through median sternotomy. At this time using a spiral great saphenous vein graft (Figure 1). The patient reported symptoms relief and was discharged four days after the operation. The patient is being followed for a period of 15 years with duplex scan and computed tomographic angiography (Figure 2). He remains asymptomatic and continues to have a patent graft.

Figure 1- Spiral saphenous vein graft: a) longitudinal opening of the saphenous vein, b) spiral anastomosis of the vein on a thorax drain and c) final result.

Figure 2- Computed tomographic angiography: a) right atrium, b) right internal jugular vein, c) spiral bypass of the internal saphenous vein and d) an occluded PTFE prosthesis.

DISCUSSION

Fibrosing mediastinitis is the most common benign cause of SVCS. Presence of a thick and fibrotic tissue can cause compression of the superior vena cava, leading to venous hypertension upstream. The clinical presentation of this syndrome includes edema of the face, neck and upper limbs in addition to facial plethora and collateral circulation in the thoracic wall. The patient complains of feeling of weight in the head, dyspnea and orthopnea, headaches, visual alterations, periorbital pain and coughing.^1-3 Although fibrosing mediastinitis could be caused by tuberculosis and systemic mycoses, in most cases the cause is unknown (idiopathic).

In contrast to malignant diseases, compression of the superior vena cava due to idiopathic fibrosing mediastinitis has a slow and progressive course. For this reason, conservative treatment is the treatment of choice while awaiting the development of collateral circulation that, in most cases, relieves the venous hypertension symptoms. When the clinical treatment fails or the patient presents neurological compromise or upper airway obstruction), invasive treatment is mandatory.^1,3,5

There are many options available for this procedure, concerning the type of conduit to be used. Doty et al. were the first to successfully use the spiral saphenous vein in the treatment of SVCS.¹ The patient remained asymptomatic with a patent and graft during a 15-year follow-up. This technique, however, was initially described by Chiu et al.6 as a substitute for large vessels. For SVCS caused by benign diseases, this type of graft shows better long-term patency than synthetic prostheses. However, some authors report complexities and time demand in this graft confection, difficulty in handling and high rate of thrombosis due to the long suture line.¹

The PTFE is also used as a vascular substitute in the treatment of SVCS. The PTFE is used preferably in the case of malignant disease associated with SVCS. This preference is based on the fact that the PTFE is more resistant to extrinsic compression than autogenous grafts. The patency of the PTFE in this situation is difficult to evaluate because the majority of these patients go on to die from the basic disease within a few years. The patency reported in literature is 86% in three to five years.⁷

Other options available are the superficial femoral vein and homologous grafts.⁷ The use of the superficial femoral vein as a graft was described in 1951. Some authors affirm that this type of conduit is easily handled, and is technically easier and faster to obtain than the spiral saphenous vein graft. However, lower limb edema after the femoral vein removal can be significant and uncomfortable.^8-10

During recent years, endovascular techniques have also been used in the treatment of SVCS.¹¹ The experience of angioplasty with self-expandable or balloon-expandable stents in this situation is still restricted. However, the initial results are promising with a success rate and primary patency of 95%. Secondary patency is of 74% in five years; however, the need for reintervention for restenosis is not uncommon.¹⁰ For the time being, endovascular treatment is reserved for seriously ill patients with a malignant disease and a low life expectancy.¹¹

In the cases of SVCS caused by benign disease, in patients with long life expectancy, the venous graft presents favorable long-term results.¹

REFERENCES

1. Doty DB, Doty JR, Jones KW. Bypass of superior vena cava. Fifteen years experience with spiral vein graft for obstruction of superior vena cava caused by benign disease. J Thorac Cardiovasc Surg 1990;99:889-96.

2. Seibel AC, Baptista-Silva JCC, Miranda F Jr. Síndrome da veia cava superior: diagnóstico e tratamento vascular. Rev Bras Clin Terap 2002;28:133-6.

3. Glovicski P, Vrtiska TJ. Surgical treatment of superior vena cava syndrome. In: Rutherford RB. Vascular Surgery. Philadelphia: W. B. Saunders; 2000. p. 2093-2103.

4. Tovar-Martin E, Tovar-Pardo AE, Marini M, Pimentel Y, Rois JM. Intraluminal leiomyosarcoma of the superior vena cava: a case of superior vena cava syndrome. J Cardiovasc Surg 1997;38:33-5.

5. Inase N, Ichioka M, Akamatsu H, Usui Y, Miyake S, Yoshizawa Y. Mediastinal fibromatosis presenting with superior vena cava syndrome. Respiration 1999;66(5):464-6.

6. 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(6):555-60.

7. Dartevelle PG, Chapelier AR, Pastorino U, et al. Long-term follow-up after prosthetic replacement of superior vena cava combined with resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259-65.

8. Ohri SK, Lawrence DR, Townsend ER. Homograft as a conduit for superior vena cava syndrome. Ann Thorac Surg 1997;64:531-3.

9. Gladstone DJ, Pillai R, Paneth M, Lincoln JCR. Relief of superior vena caval syndrome with autologous femoral used as a bypass graft. J Thorac Cardiovasc Surg 1985;89:750-2.

10. Marshall WG Jr, Kouchoukos NT. Management of recurrent superior vena caval syndrome with an externally supported femoral vein bypass graft. Ann Thorac Surg 1988;46:239-41.

11. Chacon Lopez-Muniz JI, Garcia Garcia L, Lanciego Perez C, et al. Treatment of superior and inferior vena cava syndromes of malignant cause with Wallstent catheter placed percutaneously. Am J Clin Oncol 1997;20:293-7.