RP4. Bilateral Innominate Vein and Superior Vena Cava Reconstruction Using Cryopreserved Descending Aortic Homografts

A 77-year-old man presented with superior vena cava (SVC) syndrome and chest pain. Initial chest CT showed a 4.9 x 3.2 cm anterior mediastinal mass (Figure 1A) with tumor thrombus occluding the SVC and extending into the left innominate vein, right internal jugular vein, and right atrium (RA) (Figure 1B). After two cycles of paclitaxel and carboplatin, the mass progressed to 5.8 x 3.4 cm, prompting surgical intervention. Cardiopulmonary bypass was planned preoperatively given the extensive intra-luminal thrombus.

A median sternotomy was performed and the mass was dissected free from the anterior chest wall. It was adherent to the left lingula requiring a stapled wedge resection to extract the mass en-bloc. The pericardium and pericardial fat were resected close to both phrenic nerves, which were preserved. Due to the thrombus burden in the SVC and RA precluding central venous cannulation, we percutaneously cannulated the right femoral vein. Both innominate veins were directly cannulated using 18-Fr right angled cannulas, past the area of gross tumor involvement. The aorta was cannulated in the usual fashion and cardiopulmonary bypass was initiated.

Once on bypass, we turned our attention back to the thymic mass, which was found to be invading through the left innominate vein. The innominate veins were transected just proximal to the cannulas. The SVC was transected around the mass, which was extracted carefully from the right atrium (Figure 1C). We thawed two pieces of cryopreserved descending aortic homograft, one 16-mm in diameter and the other 11-mm. One end of the 16-mm homograft was anastomosed to the remnant SVC and the other end was anastomosed to the right innominate vein (Figure 1D, green arrow). The 11-mm homograft was cut to size, anastomosed to the remnant left innominate vein, and the proximal end anastomosed in an end-to-side fashion to the newly created "neo SVC" (i.e., the 16-mm homograft) (Figure 1D, yellow arrow).

Pathology showed a 9cm pT3N0 squamous cell carcinoma with 0/8 lymph nodes. There was a positive vascular margin and he underwent adjuvant radiation therapy. At four months follow-up, there is no evidence of graft failure and the patient continues outpatient oncologic therapy. This case demonstrates the advantages of cryopreserved aortic homografts over synthetic grafts for complex venous reconstruction, offering superior handling and potentially lower infection and thrombosis risks in the setting of active malignancy.

Benjamin Shou (1), Lillian Tsai (1), Oluwatomisin Obafemi (1), Jack Boyd (1), Natalie Lui (1), (1) Stanford University, Stanford, CA

Benjamin Shou

Poster Presenter

Benjamin L. Shou, MD, is a first year integrated cardiothoracic surgery resident at Stanford. He went to medical school at Johns Hopkins and received a bachelor's from UCLA.