Technique of Superior Vena Cava Resection for Lung Carcinomas

Surgical incisions used to approach SVC resection and reconstruction. (A) A posterolateral thoracotomy, usually through the fourth or fifth intercostal space, is the most commonly used approach. (B) A median sternotomy should be considered for mediastinal tumors involving the SVC or possibly if a right carinal pneumonectomy is needed. (C) A right hemi-clamshell incision can also be performed and may be helpful for tumors that also require a significant amount of posterior mediastinal dissection.

SVC involvement by lung cancer. Right upper lobe tumors are the most frequent location for lesions involving the SVC. Caval involvement by the tumor typically occurs superior to the caval-azygos junction. n. = nerve; SVC = superior vena cava; v. = vein.

Tangential resection of the SVC. Tumors with minimal SVC involvement can be excised with the aid of partial occlusion clamp. Before beginning the tangential resection of the lateral portion of the caval wall, it is wise to have proximal and distal control of the SVC with umbilical tapes. n. = nerve; SVC = superior vena cava; v. = vein.

Pericardial patch closure of the SVC defect. Although primary repair of very small caval defects is possible, most defects require an autologous or bovine pericardial patch to avoid narrowing of the SVC luminal diameter. SVC = superior vena cava; v. = vein.

Completed SVC patch closure with phrenic nerve preservation. It is not always possible to preserve the phrenic nerve, but when possible, this should be performed. Division of the azygos vein facilitates exposure to the distal SVC and the subsequent placement of vascular clamps. n. = nerve; SVC = superior vena cava.

Extensive tumor involvement of the SVC. When tumors involve more than 50% of the circumference of the SVC, complete resection and reconstruction of the SVC is indicated. As discussed in the text, this requires careful preoperative planning and strategies to enhance volume loading as well as systemic anticoagulation. SVC = superior vena cava; v. = vein.

Complete SVC resection and reconstruction. (A) Following resection of the SVC, the operator needs to ensure that the proximal and distal margins are histologically free of malignancy. In general, there is no need to reconstruct the left innominate vein provided there are adequate collaterals. (B) Given that the transected edges of the cava will retract toward the base of the clamps, one needs to ensure that there are ample cuffs of caval wall to sew in the graft. The proximal portion of the graft is typically sewn in first. SVC = superior vena cava; v. = vein.

Less common reconstructive techniques to re-establish upper body venous contiguity. (A) Occasionally the right subclavian and jugular venous systems are either occluded or surgically absent. Under these circumstances the distal SVC is reconstructed to the left innominate vein. (B) Under very rare circumstances (described in the text), the operator may need to reconstruct both the right and the left innominate venous systems. SVC = superior vena cava; v. = vein.