Successful repair of total anomalous pulmonary venous connection and incomplete endocardial cushion defect associated with left isomerism

Successful repair of a 8-month-old girl with polysplenia was reported. The cardiovascular anomalies were TAPVC (II b), incomplete ECD, interruption of inferior vena cava with hemiazygos continuation, bilateral superior vena cava, and left superior vena cava draining into the coronary sinus. Cardiopulmonary bypass was established with ascending aortic perfusion and caval cannulation. A left superior vena cava was directly cannulated after establishing partial bypass. In this case the left pulmonary vein drained into the right atrium near the orifice of the coronary sinus, so the atrial septal flap was made and sutured between the orifice of the left pulmonary vein and the coronary sinus in order to avoid late pulmonary vein obstruction. Then, atrium was separated by an intraatrial baffle which was sutured to the atrial septal flap. Recently, it becomes possible to surgical repair of polysplenia syndrome according to the advancements of the diagnostic methods, cardiopulmonary bypass, and the technique of the open heart surgery.     

Carpal tunnel syndrome in amyotrophic lateral sclerosis and late onset cerebellar ataxia

We report two cases of tricuspid valve replacement for tricuspid valve insufficiency as reoperations following mitral valve replacement through midline sternotomy. A right thoracotomy was used to approach the tricuspid valve. To avoid the risk of cardiac laceration, cardiopulmonary bypass was instituted after cannulation of the femoral artery and of superior vena cava through right atrium with balloon caval occlusion and inferior vena cava through the femoral vein with balloon caval occlusion. Without aortic cross clamping under mild hypothermia, right atriotomy was performed through adherent parietal pleura, pericardium, and right atrial wall without dissection. Tricuspid valve was replaced utilizing the bioprosthetic valve with good clinical results. These new measures were expeditiously carried out without dissection of the heart, which has been deemed to be the risk of reoperations.     

Leiomyosarcoma of the superior vena cava. A first case with resection

Leiomysarcomas, rare malignant tumors of the veins, are located predominantly in the inferior vena cava. We report our experience with a leiomyosarcoma in the superior vena cava of a 44-year-old white man. The lesion had been locally excised and then recurred 2 1/2 years later. The recurrent tumor was widely excised and the superior vena cava was repaired with a saphenous vein patch graft. The area of the recurrence was treated with cobalt 60 therapy. Four years later, 6 1/2 years after initial treatment, the patient is alive and well without evidence of recurrence.     

Solitary intra-articular osteochondroma of the fingers in children

Injuries to the hepatic veins and retrohepatic vena cava have a high mortality due to uncontrolled hemorrhage. Successful repair may necessitate interruption of flow through the retrohepatic vena cava. Active bypass of the area is then needed to provide adequate venous return. Published methods for active bypass require cannulation of axillary and femoral veins in addition to clamping of the vena cava above and below the liver, often with limited exposure and significant risk. This report describes active bypass of the retrohepatic vena cava utilizing two right atrial cannulae. The simplicity of establishing the bypass together with the excellent exposure allowed repair of a bullet wound of the vena cava in one patient and the orderly performance of a left trisegmentectomy for a huge hepatic tumor in a second patient.     

Abdominal CT findings when the superior vena cava, brachiocephalic vein, or subclavian vein is obstructed

OBJECTIVE: We evaluated findings on contrast-enhanced abdominal CT scans that suggest obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein. SUBJECTS AND METHODS: We conducted a retrospective review of 22 patients with superior vena caval, brachiocephalic vein, or subclavian vein obstruction and analyzed the upper abdominal images on a chest CT scan or an abdominal CT scan. We assessed collateral vessels in the upper abdomen to answer the following question: Did enhancement approach undiluted IV contrast or were there other findings? In the second part of our study, we conducted a prospective review of abdominal CT scans of 200 patients without known mediastinal disease or known upper extremity venous occlusion to determine the frequency of abnormal enhancement of these vessels in a healthy population. RESULTS: The groups of collateral vessels revealed on abdominal CT scans were azygos or hemiazygos veins, internal mammary veins, lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus veins, and small mediastinal collateral veins. In the retrospective series, one patient had focal enhancement of the liver and early inferior vena caval enhancement due to collateral vessels. In the prospective series, abdominal CT scans of two patients (1%) revealed dense undiluted enhancement of one or more groups of collateral vessels: One patient had an ipsilateral pacemaker, and the other patient had an anterior neck phlegmon to the upper mediastinum. Both conditions may have been factors in the revealing of the collateral vessels. Two other patients (1%) in the prospective series had mild to moderate vessel enhancement that was less than that from undiluted contrast material. In one of these patients, the enhancement was related to abdominal wall hyperemia after surgery. In the other patient, enhancement may have been the result of ipsilateral axillary nodes. CONCLUSION: On upper abdominal CT scans, dense undiluted contrast material in the collateral vessel groups that we studied suggests possible obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein.     

Infection and superior vena cava syndrome after pacemaker implantations: major consequences of a minor intervention

Two men, aged 71 and 56 years, with pacemakers, developed the superior vena cava syndrome one and five years, respectively, after infection of the pacemaker pocket. They had been treated with antibiotics and partial removal of the foreign bodies. The conditions of both included occlusion of the superior vena cava and of both subclavian veins. The symptoms disappeared after removal of the total pacemaker system and venous reconstruction. The possibility of a superior vena cava syndrome occurring is increased if other complications have occurred previously, particularly infection. Prevention and treatment comprise on the one hand prevention and treatment of the infection (which is not always obvious) and on the other, earliest possible detection of thromboembolisms.     

Spinal canal stenosis syndrome by venous collateralization of an inferior cava thrombosis

We described in 1988 the case of a young patient with a right iliac vein and vena cava thrombosis who developed lubagoes and intermittent claudication of paralytic type. A digital venography by left femoral approach showed a derivation via the lumbar vein towards the spinal plexus. Later, the patient experienced a left external iliac vein thrombosis. Subsequently, collaterization went through the truncal veins and the clinical manifestations of the tight spinal canal disappeared. Since then, several cases of chronic thrombosis of the left primary iliac veins have been discovered. These also showed unexplained lumbagoes of the same duration. The idea of a relation of cause and effect was seldom accepted by the patients, which prevented us to proceed to many venous catherisms. Also, we performed only one operation until now: the cesarean of an ascending lumbar vein. In this very case, the tight spinal canal symptoms disappeared but appeared again after a few month-time for unknown reasons. Only one acute case has been found up to now: a woman who delivered by ligation suffered from lumbagoes and sciaticae. A dilatation of spinal veins and a lower vena cava thrombosis were showed by tomography. This woman had no leg symptom and lumbagoes disappeared with the partial recanalization of the cava.     

Vascular reconstruction using left renal vein graft in advanced hepatobiliary malignancy

BACKGROUND/AIMS: In surgical resection for advanced hepatobiliary malignancies involving the portal vein and inferior vena cava, vascular reconstruction is usually required. We utilized left renal vein grafts for vascular reconstruction in cases of these malignancies, and their clinical significance is evaluated in this study. METHODOLOGY: Left renal vein grafts were utilized for reconstruction of the portal vein in four patients and patch repair of the inferior vena cava was performed in two patients with advanced hepatobiliary malignancies. All six patients underwent hepatic resection with vascular resection and reconstruction. Postoperative renal function and graft patency were assessed. RESULTS: Transient slight renal disturbances appeared in some patients, but there was no severe renal dysfunction requiring specific therapy. Graft patency was maintained during the follow-up period in all patients. CONCLUSION: The use of left renal vein grafts as autovein grafts seems appropriate in cases involving reconstruction of the portal vein and in those involving patch repair of the inferior vena cava defect in surgical resection for advanced hepatobiliary malignancies.     

Intermittent edema of the upper and lower extremities and the abdominal wall caused by membranous stenosis of the superior vena cava and membranous obstruction of the inferior vena cava

We report on a 38-year-old patient with intermittent edema of the lower legs, arms and abdominal wall. The cause for his tendency to develop edema was a membranous obstruction of the inferior vena cava and a membranous stenosis of the superior vena cava. The etiology of these anomalies of the vena cava suggests a congenital malformation. In consideration of the cases of inferior and/or superior vena cava-anomalies published to date the patient received an anticoagulant therapy (coumarin) and treatment with graduated compression stockings. He now complains from time to time of a sensation tension in the lower legs after prolonged standing or sitting. Edema of the upper and lower extremities and the abdominal wall have disappeared.     

Orthotopic transplantation of a partial hepatic autograft in dogs

The purpose of this study was to investigate the availability of an orthotopic transplantation of partial hepatic autograft in dogs as a means of surgical training. Male mongrel dogs weighting 10-15 kg were used. The left lobe of the liver was harvested while preserving the left branches of the portal vein, hepatic artery and bile duct, and the left hepatic vein. The remnant liver was removed while preserving the inferior vena cava using a veno-venous bypass. Orthotopic transplantation of the autograft was performed while anastomosing the left hepatic vein to the inferior vena cava, portal and arterial reconstruction, and external biliary drainage. Thirteen out of 29 dogs survived more than 48 h after transplantation. However, 6 out of 13 dogs were sacrificed after developing bile peritonitis due to a dislodgement of the biliary catheter, and only two dogs were able to survive for 7 days after transplantation. The arterial ketone body ratio recovered to 1.0 within 1 h after reperfusion, and the ratio of the dogs that survived for more than 48 h remained above 1.0 until sacrifice. Orthotopic transplantation of a partial hepatic autograft is a useful and simple procedure to train surgeons for partial liver transplantation.     

Thrombosis of the superior vena cava and lateral-cervical lymphadenopathy (probably of metastatic origin). Report of a case

The authors describe a case of superior vena cava thrombosis with laterocervical lymphoadenopathy (probably of metastatic origin). Vascular tumors are a large neoplasm family with a wide clinical and histological spectrum. They may localize on the skin, soft tissues, liver, spleen and parotid gland. The case describes a 65 year-old male, affected by COLD and chronic hepatitis. He came to the hospital for strong gastric pain, which did not vary with meal assumption and objectivity of inflated superficial veins of arms, jugular veins, chest superficial veins and venous capillars and of the epigastric zone, accompanied with right laterocervical lymphoadenomegaly. Endoscopic ultrasonic and X-ray examinations showed a superior vena cava thrombosis determining superficial collateral, azygos and emiazygos vein inflation. The histologic examination of pathologic lymph nodes resulted as hemangioendotelioma/angiosarcoma, a rare case of lymphonodal vascular tumor with a very poor prognosis.     

Considerable plasma levels of a cytotoxic etoposide metabolite in patients undergoing high-dose chemotherapy

A 13-year-old boy with a paratesticular embryonal rhabdomyosarcoma and a large thrombus into the inferior vena cava reaching the suprahepatic vein is presented. We used cardiopulmonary bypass with deep hypothermic circulatory arrest to realize a complete exeresis of the tumor and thrombus, followed by systemic chemotherapy and radiotherapy. Ten years later the patient is alive and doing well without any sequelae.     

Perioperative severe rhabdomyolysis revealing susceptibility to malignant hyperthermia

Resection of extensive lung cancers invading thoracic vascular structures (T4 lesions) can yield long-term survival provided the margins and nodes are free of tumor. We report the resection of the suprahepatic inferior vena cava for direct tumor involvement by a pulmonary malignancy. The resection was performed without bypass, and the cava was subsequently reconstructed with a 22-mm-diameter Dacron graft. Patency was documented on postoperative magnetic resonance angiograms. The patient was discharged home on postoperative day 10 without complications and remains well 8 months after the operation. Potentially curative resections and reconstructions of suprahepatic inferior vena cava involved with pulmonary malignancies are possible and can be done without cardiopulmonary bypass.     

Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)

BACKGROUND: The purpose of this study was to determine the correlation between progression and regression of myointimal hyperplasia (MH) and cytokine production in experimental vein grafts. Although the autologous vein is the best suitable bypass conduit for reconstruction of peripheral arteries, at the end of the first year thrombosis in the coronary and lower extremity circulation ranges from 20% to 50%. Many of these failures are caused by MH. METHODS: In 76 inbred Lewis rats, a 1 cm long segment of inferior vena cava was inserted at the level of the abdominal aorta. The segments of inferior vena cava were obtained from syngeneic Lewis rats. In 56 animals the arterial vein graft was explanted 3 days (n = 10), 7 days (n = 10), 4 weeks (n = 26), and 12 weeks (n = 10) after operation. In 20 animals the vein graft was explanted 4 weeks after being in the arterial system and reimplanted as iliac venovenous bypass in syngeneic Lewis rats. These grafts were explanted 2 weeks (n = 10) and 8 weeks (n = 10) later. Grafts were analyzed by light and electron microscopy, morphometric study, and histochemical analysis and were put in an organ culture to assess cytokine production. RESULTS: We observed MH formation in arterial vein grafts and MH regression in reimplanted vein grafts (p < 0.001). MH formation was correlated with production of platelet-derived growth factor, basic fibroblast growth factor, interleukin-1, and tumor necrosis factor-alpha. MH regression was correlated with transforming growth factor-beta 1 production. CONCLUSIONS: On the basis of the results of our study, we conclude that MH formation in experimental vein grafts depends on production of platelet-derived growth factor, basic fibroblast growth factor, interleukin-1, and tumor necrosis factor-alpha, and MH regression depends on transforming growth factor-beta 1 production. Cytokine therapy may represent a valuable new treatment to prevent vein bypass failures caused by MH.     

Hepatic vein reconstruction at inferior vena cava confluence using left renal vein graft

BACKGROUND/AIMS: To preserve remnant liver function, extended left hepatectomy combined with middle hepatic vein reconstruction using a left renal vein graft was performed in resection of liver metastasis from sigmoid colon cancer, involving the confluence of the middle and left hepatic veins. METHODOLOGY: The tumor, 5 cm in size, occupied the superior part of segment 4, and involved the confluence of the middle and the left hepatic veins. An extended left hepatectomy, including the left lobe, left caudate lobe and part of segment 8, together with the middle hepatic vein trunk, was performed. The left renal vein was resected as a graft from the confluence of the inferior vena cava just distal to the branches of the gonadal vein, renal-azygos, splenorenal communications and vertebral veins. The middle hepatic vein was reconstructed using the left renal vein 3 cm in length. RESULTS: Impaired values of liver function tests were normalized by the third postoperative day. Renal function was good throughout the postoperative period. The patient was discharged two weeks after the surgery. The reconstructed middle hepatic vein was patent, which was evaluated by a color Doppler ultrasonography, computed tomography and magnetic resonance imaging 60 days after the surgery. The patient remained well in the eight months thereafter. CONCLUSIONS: Hepatic vein reconstruction using a left renal vein graft is a new and preferable addition for the selection of an optimal graft.     

Extraction and replacement of permanent pacemaker leads through occluded vessels: use of extraction sheaths as conduits--balloon venoplasty as an adjunct

Patients (pts) may present for lead extraction with symptomatic or asymptomatic subclavian vein or superior vena cava thrombosis. Replacement of permanent pacemaker leads (PPLs) in these pts may be difficult and may require accessing a new site. We examined the utility of replacing PPLs through completely occluded vessels using extraction sheaths as conduits through the total occlusion. Over six years, a total of 210 atrial and/or ventricular PPLs were extracted from 137 pts. Two pts presented with angiographically documented thrombotic occlusion of the subclavian vein. One additional pt. who had presented with a superior vena cava (SVC) syndrome, had a totally occluded innominate vein and SVC occlusion. Balloon venoplasty was used as an adjunct to dilate the SVC. In all pts, after PPLs were removed via a subclavian extraction sheath through the occluded vessel, the retained sheath was used to place a guide wire, then a peel away dilating sheath, to insert new PPLs, in each case on the side of total venous occlusion. Seven PPLs and two lead fragments were extracted, and five new PPLs replaced, ipsilateral to the venous occlusion. These data show that extraction of PPLs through thrombosed veins may be performed successfully and may not require replacing the leads through a new site. This technique spares the pt the need to access the opposite subclavian vein, and it avoids an excessive number of PPLs in the subclavian vein and SVC. The procedure illustrates an efficient means to reintroduce new PPLs with the potential to reduce associated morbidity, since repeat puncture of the subclavian vein is not required. Safety of the procedure as a whole must be considered with regard to the known risks of lead extraction, some complications of which may be substantial using current techniques.     

Modified repair of mixed anomalous pulmonary venous connection

A modified repair technique is reported for mixed total or partial anomalous pulmonary venous connection with the right superior pulmonary vein connecting to the superior vena cava, the right inferior pulmonary vein to the right atrium or left atrium, and the left pulmonary veins to the coronary sinus. The superior vena cava is transected above the highest right superior pulmonary vein, its cephalad end is anastomosed to the right atrial appendage, and a pericardial baffle is constructed between the cardiac ostium of the superior vena cava, the ostium of the right inferior pulmonary vein, and the left atrium, including the coronary sinus, which is unroofed. The reported technique may be valuable to avoid pulmonary venous obstruction in complex mixed forms of total or partial anomalous pulmonary venous connection.     

Transiliac catheterization of the inferior vena cava for long-term venous access in children

In infants and children requiring prolonged, multiple central venous (CV) catheterizations, the superior (SVC) and inferior vena cava may become thrombosed or stenotic, making CV access a difficult problem. Use of the iliac vein may be an acceptable alternative. We report a patient with thrombosis of the SVC in whom the external iliac vein was accessed through a retroperitoneal approach for placement of an implantable port. This technique is easy to perform, and there are no special materials or patient positioning required.     

Quality of death certificates in cases of cancer death in France

The prognosis of pulmonary tumor embolism is said to be poor and only a limited number of patients with this disease have survived. The patient was a 64-year-old male suffering from left renal cell carcinoma complicated with tumor extending from the left renal vein to the inferior vena cava. The patient underwent an operation for left renal cell carcinoma during which he developed tumor embolus to the pulmonary artery. The occurrence of the acute embolism was promptly detected and the removal of tumor was performed under cardiopulmonary bypass. The patient made good postoperative progress.     

Superior vena cava syndrome as initial manifestation of acute aortic dissection: a case report and review of the literature

Aortic dissection usually presents with chest pain, abnormal pulses and a widened mediastinum on chest radiograph. It is rarely associated with the superior vena cava syndrome as the first manifestation. This paper presents a patient who had a superior vena cava syndrome as a result of a painless aortic dissection and compared with other previously reported cases.