Hybrid surgical resection of a tumor invading the superior vena cava.

Recently, hybrid operations featuring vascular interventions have become more common, but applications in the thoracic surgery are few. Superior vena cava (SVC) resection and reconstruction is a typical complex thoracic surgery. Traditional SVC resection/reconstruction requires advanced vascular surgical skills. We developed a simple and safe procedure; we insert a stent during malignant tumor surgery involving the SVC. This approach renders such surgery easier, increasing the probability of success.

A Case Report of Reconstruction of the Left Superior Vena Cava Using the Right Superior Vena Cava Autograft at Bilateral Bidirectional Superior Cavopulmonary Anastomosis.

The choice of graft material for reconstruction of the vena cava in pediatric patients remains controversial. We successfully treated an eight-month-old female patient with single ventricle physiology and long segment obstruction of the left superior vena cava using the right superior vena cava autograft at the time of bilateral bidirectional superior cavopulmonary anastomosis. Postoperative computed tomography confirmed the patency of the reconstruction.

Repair of Persistent Left Superior Vena Cava to Unroofed Coronary Sinus Defect by Retro-Aortic Implantation (Modified Warden Type Procedure).

BACKGROUND: Repair of unroofed coronary sinus defect in the presence of left superior vena cava is challenging and requires prosthetic graft material to redirect flow to the right atrium. This may potentially cause a supra-mitral gradient or pulmonary venous obstruction. METHODS: Three patients with unroofed coronary sinus in the presence of a left superior vena cava (LSVC) underwent modified cavo-atrial anastomosis (Warden technique) to achieve reimplantation of the LSVC in a retro-aortic fashion to the right atrial appendage. RESULTS: Three patients recovered well with no evidence of an intracardiac shunt. Postoperative echocardiography demonstrated normal venous flows in the LSVC. CONCLUSION: This modified technique offers correction of this systemic venous anomaly without the need for any additional graft material.

Cross talk between vascular smooth muscle cells and monocytes through interleukin-1ß/interleukin-18 signaling promotes vein graft thickening.

OBJECTIVE: Interleukin (IL)-1ß and IL-18 are key proinflammatory cytokines that play important roles in the pathophysiology of vein graft remodeling. However, the mechanism of IL-1ß/IL-18 production and its role in the development of graft remodeling remain unclear. APPROACH AND RESULTS: IL-1ß/IL-18 were rapidly expressed in venous interposition grafts. Vascular smooth muscle cell (VSMC) death and monocytic inflammasome activation occurred in grafted veins. Necrotic VSMCs induced the expression of IL-1ß, IL-18, and other inflammasome-associated proteins in monocytes, which was partially inhibited by their antagonist, recombinant IL-1ra-Fc-IL-18bp. Activated monocytes stimulated proliferation of VSMCs by activating cell growth-related signaling molecules (AKT, STAT3, ERK1/2, and mTOR [AKT/protein kinase B, signal transducer and activator of transcription 3, extracellular signal-regulated kinase 1/2, mammalian target of rapamycin]) and increasing production of platelet-derived growth factor-bb; these effects were suppressed by IL-1ra-Fc-IL-18bp. Activated monocytes also promoted migration of VSMCs, which was independent of IL-1ß/IL-18 signaling. Importantly, administration of IL-1ra-Fc-IL-18bp inhibited activation of cell growth-related signaling molecules, VSMC proliferation, and vein graft thickening in vivo. CONCLUSIONS: Our work identified an interaction among necrotic VSMCs, monocytes, and viable VSMCs through IL-1ß/IL-18 signaling, which might be exploited as a therapeutic target in vein graft remodeling.

Focal atrial tachycardia originating from the donor superior vena cava after bicaval orthotopic heart transplantation.

An 11-year-old boy, who underwent bicaval orthotopic heart transplantation for idiopathic dilated cardiomyopathy, had a focal atrial tachycardia originating from the donor superior vena cava. The pathogenesis of this tachycardia may be related to transplant rejection or transplant vasculopathy. Radiofrequency catheter ablation can eliminate this unique tachycardia and result in hemodynamic improvement.

Superior vena cava graft for right liver and right lateral sector transplantation.

BACKGROUND: The usefulness of cryopreserved superior vena cava (SVC) grafts for venous reconstruction remains to be evaluated in right liver and right lateral sector transplantation. METHODS: Reconstruction of the hepatic vein was performed when the congested area in the liver graft was significant. A vein graft with a suitable shape and length meeting the demands for the venoplasty was selected, and SVC grafts were used in 20 recipients. Surgical techniques were classified into five types according to the necessity of middle or short hepatic vein reconstruction in the liver graft. Surgical outcomes and vein graft patency were evaluated. RESULTS: All 20 recipients survived the operation without any complications caused by congestion. Liver functions were well recovered in the early postoperative period. The 1-year primary patency rates of cryopreserved vein grafts used for reconstructed right hepatic veins, inferior right hepatic veins, and middle hepatic vein tributaries were 100%, 94%, and 42%, respectively. CONCLUSIONS: SVC grafts were feasible for outflow tract reconstruction in right liver and right lateral sector transplantation, although the long-term patency of the grafts for middle hepatic vein reconstruction remains to be evaluated.

Depopulated vena caval homograft: a new venous conduit.

OBJECTIVE: Completion of the Fontan procedure is frequently performed by using an extracardiac conduit between the inferior vena cava and the pulmonary artery. Most centers use a polytetrafluoroethylene graft for the extracardiac conduit, and because re-endothelialization is unlikely, anticoagulation is used for a variable period. This study explores the use of an alternate large-caliber venous conduit. METHODS: The superior vena cava was replaced in 8 minipigs with either a polytetrafluoroethylene interposition graft (2 pigs) or a depopulated (acellular), cryopreserved superior vena caval homograft (6 pigs). After 6 months, the animals were killed, and the grafts were examined for patency and histology, including immunostaining. No anticoagulation was used. RESULTS: Polytetrafluoroethylene grafts have a cross-sectional luminal narrowing, ranging from 16% to 40%. Histology showed only partial intimal ingrowth, with excessive subendothelial fibrosis and early calcification. In contrast, the depopulated venous homografts showed minimal luminal narrowing, ranging from 2% to 9%. These grafts were completely repopulated by the recipient with an endothelial lining, which stained positively for factor VIII, and a subendothelial region appropriately recellularized by myofibroblasts, which stained positively for smooth muscle actin and procollagen. There was no evidence of an immune response to the venous homografts, as judged by staining for T-cell surface antigen, CD4, and CD8. Thrombus was not seen in any of the grafts. CONCLUSION: Depopulated, cryopreserved vena caval homografts might be superior conduits for cavopulmonary connection during completion of the Fontan operation by using the extracardiac conduit technique.