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Journal of Case Reports
Surgical Reconstruction of Non Malignant Superior Vena Cava Syndrome by PTFE Graft

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Elias SAIKALY1, Sandy ZEIDAN2, Christian GERGES3, Michel El FEGHALY3
From the Department of General Surgery1; Department of Medicine, Nephrology Division2; Department of Vascular Surgery3; St Georges Hospital University Medical Center, Beirut, Lebanon.
Corresponding Author:
Dr. Christian GERGES
Email: christiangergess@hotmail.com
Received: 07-FEB-2014 Accepted: 22-MAR-2014 Published Online: 15-APR-2014
DOI: http://dx.doi.org/10.17659/01.2014.0030
Abstract
Non-malignant superior vena cava syndrome due to indwelling catheters is rising in prevalence, reaching 1-3% of patients with central venous catheters. Surgical treatment is curative and long-standing. More than 5 million central venous catheters are now being implanted in the United States and are associated with upper extremity or central vein deep vein thrombosis in 7-30% of patients. Herein, we present a case of 18 year old male patient with history of end stage renal disease with recurrent use of indwelling catheters for haemodialysis admitted for surgical management of non-malignant superior vena cava occlusion by PTFE graft.
Keywords : Superior Vena Cava Syndrome, Indwelling catheters, Kidney Failure, Thrombosis, Renal Dialysis.
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Introduction

The  rapid  increase  in  use  of  indwelling  central  venous  catheters  over  the past  two  decades  has  resulted  in  greater  number  of  patients  with  superior  vena  cava  syndrome  of  benign  etiology.  More  than  5  million  central  venous  catheters  are  now  being  implanted  in  the  United  States  and  are  associated  with  upper  extremity  or  central  vein  deep  vein  thrombosis  in  7-30%  percent  of  patients [1,2].  Symptoms  of  venous  congestion  of  the  head  and  neck  secondary  to  occlusion  of  the  superior  vena  cava  or  innominate  veins  develop  in  about  15,000  patient  each  year  in United  States [3].

Superior  vena  cava  syndrome  is  caused  by  malignant  tumors  of  the  lung  and  mediastinum  in  60%    of  cases.  The  most  frequent  non-malignant  cause  of  superior  vena  cava  syndrome  is  intravenous  catheters  or  pacemaker  wires,  where  superior  vena  cava  syndrome  occurs  in   1-3%  of  patients  with  central  venous  catheters. Surgical  treatment  for  benign  superior  vena  cava  syndrome  is  usually  curative  and  long lasting.

Herein,  we  report  a  case  of  18  year  old  male  patient  known  to  have  end  stage  renal  disease on  hemodialysis  with  history  of  recurrent  use  of  indwelling  catheter  admitted  for  surgical  management  of  nonmalignant  superior  vena  cava  syndrome  induced  by  venous  catheter  for  hemodialysis  using a  PTFE   graft.

Case Report

An 18  year  old  male  patient  was admitted  for  surgical  management  of  non-malignant  superior  vena  cava  syndrome  induced  by  indwelling  catheter  for  hemodialysis  by  PTFE  graft  after  failure  of  endovascular  intervention. History  dates  back  to  the  age  of  8  years,  that  is  10  years  prior  to  the  presentation,  where  the  patient  was  diagnosed,  by  kidney  biopsy,  to  have  focal  segmental  glomerulosclerosis   (FSGS)  progressing  to  end  stage  kidney  disease  requiring  dialysis.  Consequently,  arteriovenous  fistula  was  created  and  central  venous  catheter  for  hemodialysis  was  inserted  awaiting  AV  fistula  maturation.

Over  a  period  of  seven  years  the  patient  suffered  from  recurrent  AV  fistula  thrombosis  requiring  multiple  thrombectomies  and  multiple  insertions  of  central  venous  catheter  for  hemodialysis.  Meanwhile  the  patient  was  investigated  for  hypercoagulable  state  which  turned  out  to  be  negative. Over  a  period  of  7  years,  multiple  catheters  were  required  and  the  procedures  were  complicated  by  failure  to  proceed  by  catheter  to  the  level  of  atriocaval  junction.  On  the  other  hand,  the  patient  started  to  complain  of  superior  vena  cava  syndrome  symptoms  manifested  by  feeling  of  fullness  in  head  and  neck,  orthopnea,  head  and  neck  swelling. Hence,  the  diagnosis  was  confirmed  by  CT  scan  of  chest  showing  complete  occlusion  of  the  distal  superior  vena  cava.  This was followed  by  three  years  of  progressive  worsening  in symptoms  with  failure  of  conservative  measures  in  alleviating  the  patients  symptoms.  Consequently  the  patient  was  scheduled  for  endovascular  intervention  with   an  attempt  to  place  a  stent  in  the  superior  vena  cava  at  level  of  obstruction,  but  the  procedure  failed  due  to  inability  to  cross  the  occluded   superior  vena  cava [Fig.1a-c].


After  failure  of  conservative  measures  and  after  failure  of  endovascular  intervention,  surgical  treatment  was  the  only  option  left. A  surgical  reconstruction  was  performed  from  the  superior  vena  cava  to  the  level  of  right  atrium  using  a  16  mm  PTFE  graft  through  a  median  sternotomy. [Fig.1d,e]


Discussion

Patients  with  superior  vena  cava  syndrome  can  have  severe  incapacitating  symptoms  that  cannot  be  relieved  by  conservative  measures.  Failure  of  conservative  measures  and  endovascular  intervention  in  managing  and  relieving  the  symptoms  are  indications  for  surgical  reconstruction. Surgical  treatment  of  superior  vena  cava  syndrome  can  be  performed  using  great  saphenous  vein  graft,  femoral  vein  graft,  spiral  saphenous  vein  graft  and  PTFE.  Patients should   be individualized when surgery is indicated.

Our  choice  was  PTFE  due to  unavailability  of  large  diameter  autologous  vein  to  be  used  as  a  conduit , and the  poor  size  match  of  the  great  saphenous.  Added to this  was  underlying thrombotic abnormality in our patient, manifested by recurrent AV fistula  thrombosis,  making  the choice of femoral vein  as  a  conduit  not  optimal.  This  is  due  to  the  underlying  risk  of  edema,  pain,  compartment  syndrome,  and  chronic  venous  insufficiency  after  removal  of  deep  leg  veins  in  patients  with  thrombotic  abnormalities [4,5]. Besides,  the  excellent  long  term  patency  of  short  and  large  diameter  PTFE  grafts  when  used  for  large  vein  reconstruction   made  PTFE  our  best  choice [6,7].   On  the  other  hand,  the  already  present  AV  fistula  in  the  right arm  will ensure  long  lasting  patency  of  the  graft [8].

The  patient  tolerated  the  reconstruction  well,  where  complete  relief  from  orthopnea was  noted  soon after surgery and  50% decrease  in  neck edema was seen next day.  

Conclusion

Surgery  for  nonmalignant  superior  vena  cava  syndrome  is  usually  curative  and  long  lasting.  Surgical reconstruction  is  indicated  after  failure  of  conservative  measures  and  failure  of  endovascular  intervention.  Patients should be individualized while choosing the material of reconstruction.

References
  1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics-2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69.
  2. Korkeila P, Nyman K, Ylitalo A, Koistinen J, Karjalainen P, Lund J, et al. Venous obstruction after pacemaker implantation. Pacing Clin Electrophysiol. 2007;30:199.
  3. Wilson LD, Detterbeck FC, Yahalom J. Superior vena cava syndrome with malignant causes. N Engl J Med. 2007;356:1862.
  4. Wells JK, Hagino RT, Bargmann KM, et al. Venous morbidity after superficial femoral-popliteal vein harvest. J Vasc Surg. 1999; 29:282-289.
  5. Modrall JG, Hocking JA, Timaran CH, Rosero EB, Arko FR 3rd, Valentine RJ, et al. Late incidence of chronic venous insufficiency after deep vein harvest. J Vasc Surg. 2007; 46:520.
  6. Gloviczki P, Pairolero PC. Prosthetic replacement of large veins. In: Bergan J, Kistner RL, ed. Atlas of Venous Surgery, Philadelphia, PA: WB Saunders; 1992:191.
  7. Jost CJ, Gloviczki P, Cherry KJ, McKusick MA, Harmsen WS, Jenkins GD, et al. Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease. J Vasc Surg. 2001;33:320.
  8. Magnan PE, Thomas P, Giudicelli R, Fuentes P, Branchereau A. Surgical reconstruction of the superior vena cava. Cardiovasc Surg. 1994; 2:598.
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SAIKALY E, ZEIDAN S, GERGES C, El FEGHALY MSurgical Reconstruction of Non Malignant Superior Vena Cava Syndrome by PTFE Graft.JCR 2014;4:120-122
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SAIKALY E, ZEIDAN S, GERGES C, El FEGHALY MSurgical Reconstruction of Non Malignant Superior Vena Cava Syndrome by PTFE Graft.JCR [serial online] 2014[cited 2024 Mar 29];4:120-122. Available from: http://www.casereports.in/articles/4/1/Surgical-Reconstruction-of-Non-Malignant-Superior-Vena-Cava-Syndrome-by-PTFE-Graft.html
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