CTV09 - Superior Vena Cava Syndrome Requiring Median Sternotomy and CorMatrix Patch Angioplasty

Introduction/Purpose: Superior vena cava (SVC) syndrome results from any condition that leads to obstruction of blood flow through the SVC, including malignant obstruction, external compression by adjacent mediastinal structures, or central venous obstruction associated with upper extremity hemodialysis access. Thoracic central venous obstruction resulting from hemodialysis access can be due to SVC thrombosis and/or stenosis.

Methods or Case Description: A 39-year-old Hispanic male with end-stage renal disease on hemodialysis via left upper extremity arteriovenous (AV) fistula presented with severe facial and neck swelling. The patient had multiple Permcath placements and bilateral upper extremity AV access surgeries. On physical exam, the patient was noted to have an edematous neck and face bilaterally, nonlabored respirations, and left upper extremity AV fistula with pulsatility. Venography was performed that showed SVC and right innominate vein occlusions. A guidewire was unable to be passed from proximal or distal approaches. The decision was made to perform an open operation. A median sternotomy was performed to expose the SVC and bifurcation of the left and right innominate veins.

Outcomes: The initial plan was to reconstruct the SVC to the left and right innominate veins using CorMatrix as a tube graft. However, significant fibrosis of the right innominate vein as well as a focal fibrotic region at the left innominate vein / SVC confluence were encountered. Treatment included focal endovenectomy and CorMatrix patch angioplasty of the left innominate / SVC. Post-operatively, the facial and neck edema resolved, the AV fistula was functional, and the patient did well at 6-month follow up.

Conclusion: Operative treatment for SVC syndrome due to central venous obstruction includes percutaneous transluminal angioplasty, endovenous stenting, interposition conduit placement, or venous bypass. Open SVC reconstruction is indicated when there is total occlusion that cannot be crossed with a guidewire or treated endovascularly. Discussion includes biologic and non-biologic open SVC reconstruction options.