Extracorporeal membrane oxygenation (ECMO) assisted huge mediastinal tumor resection combined with superior vena cava replacement: A case report and literature review.

As to huge solid mediastinal tumor which direct compression or invasion of the superior/inferior vena cava (SVC/IVC), surgical resection remains the main lifesaving treatment. However, it would present formidable anesthetic challenges due to the extremely high risks of cardiorespiratory compromise, drastic hemodynamic fluctuations and death at all perioperative stages. Here, we report a case of huge anterior mediastinal tumor resection combined with SVC replacement under the assistance of venoarterial extracorporeal membrane oxygenation (VA ECMO), and stable hemodynamics were maintained as well as high internal jugular vein pressure being avoided during the operation procedure. He was weaned off ECMO successfully just after surgery and eventually discharged. No signs of postoperatively neurological complications occurred. Therefore, the use of ECMO assistance in huge mediastinal tumor resection combined with SVC replacement is feasible and safe, which may provide the possibility of surgical treatment for such patients and improve outcomes.

Hypotensive patient with superior vena cava obstruction diagnosed using resuscitative transesophageal echocardiography.

BACKGROUND: Superior vena cava syndrome (SVCS) is a malignancy-related emergency. It is caused by obstruction of blood flow in the superior vena cava (SVC) secondary to intraluminal thrombosis, external compression, or direct invasion of tumor. CASE SUMMARY: A 49-year-old male presented to the emergency department (ED) with acute hypoxemic respiratory failure. He was intubated and treated as pneumonia. Post-intubation, he became hypotensive, requiring fluid resuscitation and inotropic support. Resuscitative transesophageal echocardiography (TEE) showed external compression by a lung mass and an intraluminal thrombus causing SVC obstruction. Computed tomography (CT) angiography was performed, and it confirmed the TEE findings. A provisional diagnosis of lung carcinoma was made, and he underwent endovascular therapy for rapid symptomatic relief. DISCUSSION: This case report highlights the role of resuscitative TEE in evaluating a hypotensive patient with clinical suspicion of SVCS at the emergency department. TEE performed at the bedside could help to diagnose and demonstrate the pathology causing SVCS in this case. TEE allowed high-quality image acquisition and was able to overcome the limitation of transthoracic echocardiography (TTE). TEE should be considered as an alternative ED imaging modality in the management of SVCS.

Systematic review of electrophysiology procedures in patients with obstruction of the inferior vena cava.

AIMS: The objective of the study was to conduct a systematic review to describe and compare the different approaches for performing cardiac electrophysiology (EP) procedures in patients with interrupted inferior vena cava (IVC) or equivalent entities causing IVC obstruction. METHODS: We conducted a structured search to identify manuscripts reporting EP procedures with interrupted IVC or IVC obstruction of any aetiology published up until August 2020. No restrictions were applied in the search strategy. We also included seven local cases that met inclusion criteria. RESULTS: The analysis included 142 patients (mean age 48.9 years; 48% female) undergoing 143 procedures. Obstruction of the IVC was not known before the index procedure in 54% of patients. Congenital interruption of IVC was the most frequent cause (80%); and, associated congenital heart disease (CHD) was observed in 43% of patients in this setting. The superior approach for ablation was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%). Electroanatomical mapping (58%), use of long sheaths (41%), intracardiac echocardiography (19%), transesophageal echocardiography (15%) and remote controlled magnetic navigation (13%) were used as adjuncts to aid performance. Ablation was successful in 135 of 140 procedures in which outcomes were reported. Major complications were only reported in patients undergoing AF ablation, including two patients with pericardial effusion, one of whom required surgical repair, and another patient who died after inadvertent entry into an undiagnosed atrioesophageal fistula from a previous procedure. CONCLUSION: The superior approach is most frequent approach for performing EP procedures in the setting of obstructed IVC. Transhepatic approach is a feasible alternative, and may provide a "familiar approach" for transseptal access when it is required. Adjunctive use of long sheaths, intravascular echocardiography, electro-anatomical mapping and remote magnetic navigation may be helpful, especially if there is associated complex CHD. With careful planning, EP procedures can usually be successfully performed with a low risk of complications.

Refractory cerebrospinal fluid leak following posterior fossa surgery secondary to superior vena cava obstruction: a case report.

We report a case of refractory post-operative cerebrospinal fluid leak from a posterior fossa operative site secondary to superior vena cava construction. The patient developed the leak after a posterior fossa craniotomy and resection of a cerebellar lung metastasis. The leak persisted despite conservative measures and lumbar drain insertion. Suspicion of superior vena cava obstruction was raised following clinical examination. She was managed with stenting of the superior vena cava, with cessation of leak.

Long Term Results of Bypass Graft to the Right Atrium in the Management of Superior Vena Cava Syndrome in Dialysis Patients.

BACKGROUND: Superior vena cava (SVC) occlusion in dialysis patients is a serious complication that can cause SVC syndrome and vascular access dysfunction. While endovascular therapy has advanced to become the first line of treatment, open surgical treatment may still be needed occasionally. However, no long term outcome data has been previously reported. METHODS: We performed a retrospective review of 5 dialysis patients treated with bypass graft to the right atrium from 2012 to 2014. Four patients had severe dysfunction of their upper arm dialysis access as well as superior vena cava syndrome, and one patient with a femoral tunneled dialysis catheter (TDC) had SVC occlusion. None of the patients were candidates for lower extremity access creation or peritoneal dialysis (PD). Three patients underwent a left brachiocephalic-right atrial bypass and 2 underwent a bypass from the cephalic fistula to the right atrium. RESULTS: All procedures were technically successful and maintained function of the arteriovenous fistulas or allowed creation of a new upper extremity dialysis graft. One-year secondary patency rate of the bypass was 100%. Longer follow up revealed that one patient died of leg sepsis and another one of a stroke within 14 months after the procedure. Another patient did well for 16 months when recurrent graft thrombosis occurred; and ultimately the graft failed after 31 months despite multiple interventions. Two patients maintained bypass graft patency during a follow up of 78 months; however, they underwent multiple endovascular interventions (23) and open vascular access procedures (4) to maintain hemodialysis function. CONCLUSION: Bypass grafts to the right atrium in dialysis patients with SVC occlusion are successful in maintaining function of already existing vascular access or new ones. Long term secondary patency can be achieved but requires strict follow up and a proactive endovascular strategy to treat lesions in the access and or the bypass graft.

Shock due to superior vena cava obstruction detected with point of care ultrasound.

Superior Vena Cava (SVC) syndrome is caused by SVC obstruction by external compression or intraluminal thrombus. Patients with the condition can present with upper body swelling, shortness of breath and shock. This case report highlights the use of point-of-care ultrasound (POCUS) to evaluate a patient with SVC syndrome in the emergency department. The test offers many advantages over computed tomography (CT), venography, and magnetic resonance imaging which are limited in hemodynamically unstable patients. A 60-year-old male presented with acute respiratory distress and shock. The POCUS showed the presence of a right lung consolidation and SVC thrombus. CT revealed the presence of a large mediastinal mass causing compression of the SVC with clot seen inside the vessel. The patient was thrombolysed with intravenous streptokinase and his hemodynamics improved. Further investigation confirmed the diagnosis of lymphoma. The SVC can be visualized with transthoracic echocardiography using either the suprasternal, right supraclavicular or right parasternal approach. In this case, the presence of consolidation of the right lung mass provided an acoustic window for the visualization of the SVC using the right parasternal view, thereby allowing for more rapid diagnosis and management.

Unusual collateral vessel from right subclavian vein to left atrium, a rare complication of superior vena cava obstruction.

The most commonly reported collateral systems in the setting of superior vena cava obstruction are azygos venous system, vertebral venous system, external and internal thoracic venous system based on McLntire and Sykes classification. A 49-year-old female with renal disease complained dyspnea on exertion. Transesophageal echocardiography showed significant mitral annular calcification, large multi-lobulated mass at posterior aspect of RA, and complete obstruction of superior vena cava by thrombus formation. Computed tomography angiography showed a collateral vein to the left atrium (LA) roof. This case report is the first one which shows development of collateral vein from right subclavian to LA.

CT of the bronchopulmonary veins in patients with superior vena cava or left brachiocephalic vein obstruction.

OBJECTIVE: The purpose of this study was to show the arrangement and connections of the bronchopulmonary veins (i.e., vessels draining the bronchi, bronchioles, and pleura in patients with chronic superior vena cava (SVC) or left brachiocephalic vein (LBCV) obstruction using CT. MATERIALS AND METHODS: Contrast-enhanced CT scans of the chest of 16 patients with chronic SVC or LBCV obstruction were analyzed retrospectively. Scans were acquired using various standard protocols. The mean age of the patients (10 men and six women) was 63 years (range, 41-86 years). The causes of obstruction were malignancy (7/16, 44%), catheter-related thrombosis (7/16, 44%), chronic fibrosing mediastinitis (1/16, 6%), and unknown (1/16, 6%). RESULTS: The following sites were obstructed: SVC (9/16, 56%), SVC below the azygos vein (4/16, 25%), and lower LBCV (3/16, 19%). The bronchopulmonary veins were opacified via the brachiocephalic, azygos, or accessory hemiazygos veins or their branches. We observed long vessels that could be traced along the lateral mediastinum or alongside the trachea and central bronchi to their termination in the central pulmonary veins from the level of the ostia to segmental divisions. These vessels intercommunicated and gave rise to smaller veins contiguous with the walls of the bronchi and pulmonary arteries. The pulmonary venous connections of the bronchopulmonary veins were more frequent with the lower lobe pulmonary veins. Pericardial and esophageal veins were also opacified through the brachiocephalic or azygos veins and anastomosed commonly with the bronchopulmonary veins. CONCLUSION: The arrangement and connections of the bronchopulmonary veins in patients with chronic SVC or LBCV obstruction can be depicted by CT; these vessels form an intricate network connecting the systemic and pulmonary venous circulations and can act as systemic-pulmonary shunts.

Computed tomographic characteristics of collateral venous pathways in dogs with caudal vena cava obstruction.

Collateral venous pathways develop in dogs with obstruction or increased blood flow resistance at any level of the caudal vena cava in order to maintain venous drainage to the right atrium. The purpose of this retrospective study was to describe the sites, causes of obstruction, and configurations of venous collateral pathways for a group of dogs with caudal vena cava obstruction. Computed tomography databases from two veterinary hospitals were searched for dogs with a diagnosis of caudal vena cava obstruction and multidetector row computed tomographic angiographic (CTA) scans that included the entire caudal vena cava. Images for each included dog were retrieved and collateral venous pathways were characterized using image postprocessing and a classification system previously reported for humans. A total of nine dogs met inclusion criteria and four major collateral venous pathways were identified: deep (n = 2), portal (n = 2), intermediate (n = 7), and superficial (n = 5). More than one collateral venous pathway was present in 5 dogs. An alternative pathway consisting of renal subcapsular collateral veins, arising mainly from the caudal pole of both kidneys, was found in three dogs. In conclusion, findings indicated that collateral venous pathway patterns similar to those described in humans are also present in dogs with caudal vena cava obstruction. These collateral pathways need to be distinguished from other vascular anomalies in dogs. Postprocessing of multidetector-row CTA images allowed delineation of the course of these complicated venous pathways and may be a helpful adjunct for treatment planning in future cases.

Syncope Due to Iatrogenic Cava Vein Obstruction: Rare Complication of Cardiac Implantable Electronic Device Leads.

A 77-year-old female patient with multiple pacemaker leads experienced hypotension and syncope during right heart catheterization. Imaging studies revealed a stenotic inferior vena cava with superior vena cava obstruction and well-developed retrograde collateral vessels, suggesting that balloon obstruction of the sole venous return site caused low cardiac output leading to syncope.

The difficulties of recanalization in chronic superior cava vein obstruction by penetrating diagnostic catheter, PTA, and stenting: A case report.

Superior vena cava obstruction is caused by a blockage in its blood flow; one of its few causes can be device related. This case follows a patient presented with superior vena cava obstruction following a septal cardiac implant. Endovascular intervention has been associated with more rapid, complete symptom relief and lower complication rates. The use of stenting as first-line therapy has gathered popularity to become standard practice in the past 2 decades. This paper illustrates a successful recanalization with penetrating diagnostic catheter, followed with percutaneous transluminal angioplasty stenting in order to preserve the patency superior vena cava.

Management of cerebrospinal fluid rhinorrhea as a rare complication of antiphospholipid syndrome.

Background: Antiphospholipid syndrome is a complex autoimmune condition associated with the formation of recurrent thrombosis in any vascular bed throughout the body. Jugular vein thrombosis is very rare with only a 0.9% occurrence and is not typically associated with cerebrospinal rhinorrhea as a result of raised intracranial pressure. Case Description: A 54-year-old patient presented with a 9-month history of cerebrospinal fluid (CSF) rhinorrhea and headache on a background of antiphospholipid syndrome. Investigations showed a superior vena cava (SVC) and right internal jugular vein (IJV) obstruction with moderately elevated intracranial venous pressures. Her magnetic resonance imaging (MRI) brain was consistent with a CSF leak. The patient underwent successful endovascular stenting of her obstructed SVC and right IJV followed by surgical repair of a herniating meningocele in the posterior left ethmoid air cells. Conclusion: CSF rhinorrhea is uncommon and never previously reported associated with SVC thrombosis induced by antiphospholipid syndrome. A combination of endovascular techniques and surgical repair is recommended for this challenging presentation.

Unveiling the culprit: Exploring malignant thrombotic superior vena cava obstruction.

This case image describes the complex proposed etiologies of a case of superior vena cava syndrome. Hence, different diagnostic and therapeutic modalities are needed in a multidisciplinary team approach.

Ultrasound-guided intraoperative inferior vena cava stent implantation for treatment of acute hypotension during orthotopic liver transplantation.

Severe obstruction of inferior vena cava (IVC) outflow after orthotopic liver transplantation can result in persistent hypotension, leading to transplantation failure and intraoperative circulatory instability and can even threaten the patient's life. IVC stent implantation is a therapeutic approach to relieve the obstruction of IVC outflow. In the present report, we describe two cases of IVC stent implantation assisted by color Doppler ultrasound during orthotopic liver transplantation to manage the persistent hypotension caused by acute obstruction of IVC outflow. At 1 and 3 months of follow-up, the stent position was optimal, and the stent and IVC patency were satisfactory without thrombosis.

Mediastinal Bronchogenic Cyst With Superior Vena Cava Syndrome: A Case Report.

Bronchogenic cysts are rare in adults and often remain undetected until discovered incidentally on imaging or during a symptomatic investigation. The possibility of superior vena cava (SVC) compression due to a bronchogenic cyst arises in complex patient presentations. SVC syndrome poses several unique challenges due to the wide range of clinical symptoms and difficulty identifying the cause when symptoms first manifest. This case report examines a 39-year-old male who presented with symptoms resulting from SVC compression caused by a bronchogenic cyst, leading to SVC syndrome. We discuss the various imaging modalities used to assess the severity of the obstruction and the surgical interventions employed to alleviate the symptoms. A surgical intervention provides symptomatic relief and promises an excellent prognosis when performed without complications.

Downhill Varices in the Hypopharynx of a Patient with a Large Thyroid Tumor: A Case Report.

Downhill varices are usually caused by superior vena cava (SVC) obstruction due to bronchogenic carcinoma or mediastinal tumors. These structures exhibit retrograde blood flow and are located in the proximal esophagus. Varices in the hypopharynx resulting from mediastinal thyroid tumor are extremely rare. A 70-year-old man with a 35-year history of a growing thyroid tumor on the right side of his neck visited a local hospital. Fine-needle aspiration cytology of the tumor revealed benign goiter. Contrast-enhanced computed tomography showed a huge tumor (13 × 10 × 5 cm) in the right to left lobe of the thyroid that extended into the mediastinum. A well-enhanced mass mimicking hypopharyngeal cancer was identified in the hypopharynx. Endoscopic examination showed varices in the postcricoid region, so biopsy was contraindicated. The preoperative diagnosis was adenomatous goiter and hypopharyngeal varices caused by obstruction of the internal jugular and brachiocephalic vein by the goiter. Total thyroidectomy was performed and the hypopharyngeal varices had disappeared by the next day. The histopathological diagnosis of the thyroid tumor was poorly differentiated carcinoma. Mediastinal thyroid tumor rarely causes downhill varices due to SVC obstruction. However, signs of SVC obstruction were absent in this case, and varices were present in the hypopharynx, not in the upper esophagus. Obstructed venous flow from the thyroid plexus might circulate via the superior laryngeal vein and cause varices in the postcricoid region. When a patient with a large mediastinal tumor has a tumor-like lesion in the hypopharynx, downhill varices should be considered before scheduling a biopsy.

Palliative surgery for malignant superior vena cava obstruction resistant to immunotherapy: a case report.

BACKGROUND: A disease progression pattern in a limited number of sites, called oligoprogression, is relatively common in patients with lung cancer during immunotherapy. It is controversial how to manage clinically problematic oligoprogressive lesions, such as superior vena cava (SVC) obstruction resistant to immunotherapy. CASE DESCRIPTION: We present a case of a 43-year-old man who presented with facial swelling and pain in the right shoulder. Contrast-enhanced computed tomography (CT) revealed a tumor at the apex of the right lung, pulmonary and pleural nodules, and swollen mediastinal lymph nodes. A swollen mediastinal lymph node directly invaded into the SVC. Pathological diagnosis of the lymph node revealed adenocarcinoma. On the basis of these findings, the patient was diagnosed with lung adenocarcinoma with SVC obstruction (cT3N2M1c; stage IVB). First-line chemotherapy with carboplatin, pemetrexed, and pembrolizumab reduced the size of the primary tumor, pulmonary and pleural metastases, and most mediastinal lymph node metastases after four cycles of treatment, but one lesion invading the SVC increased. Therefore, surgical resection of the lesion and vascular replacement were performed. At present, 22 months have passed since the surgery, and maintenance therapy with pemetrexed and pembrolizumab is ongoing, without disease progression nor any adverse events. CONCLUSIONS: The clinical course of the case presented here suggests that palliative surgery may be an effective management option for a clinically problematic lesion, such as SVC obstruction, which increases during immunotherapy.

Refractory Hypotension During Implantation of a 70 mL Total Artificial Heart in a Patient With Pectus Excavatum: A Case Report.

The Syncardia total artificial heart system is the only commercially approved durable device for treating biventricular heart failure patients awaiting heart transplantation. Conventionally, the Syncardia total artificial heart system is implanted based on the distance from the anterior aspect of the 10th thoracic vertebra to the sternum and the patient's body surface area. However, this criterion does not account for chest wall musculoskeletal deformities. This case report describes a patient with a pectus excavatum who developed compression of the inferior vena cava after Syncardia total artificial heart implantation and how transesophageal echocardiography guided chest wall surgery to accommodate the total artificial heart system.

Left brachiocephalic vein-right atrial bypass in superior vena cava syndrome.

Superior vena cava syndrome (SVCS) is a condition with total or partial stenosis in the superior vena cava (SVC) as a result of intrathoracic malignancies or microtrauma caused by central venous catheterisation. Various invasive and surgical interventions are performed to provide venous drainage in these patients whose head and neck venous blood flow is impaired. In this case report, we report on a bypass performed with a synthetic graft between the left brachiocephalic vein and the right atrium in a patient with SVCS.