Superior vena cava and central venous reconstruction

Partial or complete obstruction of the superior vena cava and its major tributaries occassionally results in incapacitating venous hypertension of the upper extremities and/or head and neck. Factors intrinsic and extrinsic to the central veins play a role in the pathogenesis. The more common causes include mechanically and chemically induced intimal injury with resultant fibrosis, sclerosis, or thrombosis and neoplastic masses with external compression or direct extension in the central venous structures. Medical therapy is indicated in the acute situation and generally allows the time necessary for development of collateral drainage routes. Persistent or progressive symptomatic venous hypertension develops in 5% to 40% of these patients, and approximately 10% of the patients will remain incapacitated. Presented here is a series of 10 patients who underwent reconstruction of the superior vena cava or central veins for incapacitating venous hypertension of the upper extremities and/or head and neck. Reconstruction was accomplished by venous transposition (three patients), externally reinforced ePTFE (six patients), and reversed saphenous vein graft (one patient). No perioperative deaths occurred; however, two late deaths occurred at 3 and 9 months after reconstruction from causes unrelated to the operative procedure. One patient experienced early postoperative graft thrombosis requiring thrombectomy, after which the graft remained patent. All patients had patent grafts and were asymptomatic with respect to their venous disease at the time of preparation of this manuscript, with a mean follow-up period of 30 months. Specific details concerning these 10 cases are discussed and integrated with a focused review of the literature and the historic development of the intraoperative techniques and postoperative care that facilitate the successful management of patients with symptomatic central venous occlusion.