Chap 63-65 SVC Reconstruction and Venous Tumors Flashcards
What are most common cause of SVC obstruction?
Non small cell
aortic aneurysm
What are most common symptoms of SCV obstruction?
feelingo f fullness in head and neck dyspnea orthopnea H/A syncope visual disturbances
What are some less frequent symptoms?
mental confusion
hemoptysis
dysphagia
WL
What are signs on exam?
dilated neck veins
swelling of face, neck, eyelids
chest wall colaterals
arm swelling
What is pemberton’s sign?
elevation of arms until the touch side of face
facial congestion and cyanosis after one minute
indicates increase intrathoracic venous P
What are findings on CXR of SVC syndrome?
Mediastinal widening Right hilar mass Pleural effusion Infiltrates Dilated veins may be visible May be normal
What are findings on US for SVC obstruction?
Loss of normal variation in respiratory flow in subclavian
No change in diameter or flow with valsalva
Collaterals
What are findings on CT/MR?
location of obstruction
mass/tumor
collaterals
How do you do a venography for SVC obstruction?
bilat simultaneous injections of arm vein
What are important collaterals in SVC syndrome?
- azygos-hemiazygos (intercostals)
- internal mammary (inf and superios epigastric)
- lateral thoracoepigastric
- vertebral and small mediastinal veins(femoral to vertebral)
What are the type of SVC obstruction? Which is the most common?
Type I partial
Type II complet or nearly complete with flow in the azygos vein remaining antegrade
Type III is 90-100% obstruction of the SVC with reversed azygos flow
Type IV extensive mediastinal central occlusion with venous return through IVC
Type III
What are initial treatments?
conservative elevation of HOB diuresis steroids/chemo/rad (if cancer anticoag if cancer
What are invasive treatments?
endovascular first line
stent with/out CDT
surgical
How many patients resolve with chemo/rad?
80% in 4 weeks
what are indications for intervention for SVC obstruction?
indication incapacitating symptoms that cannot be alleviated by conservative measures
III and IV usually not candidates for endovascular
failure of endovascular
What is surgical option for SVC obstruction?
jugular/innominate to femoral vein/RA bypass with SVG femoral vein spiral saphenous ePTFE
What are surgical approaches?
Mediastinal reconstruction if life expectancy > 1year
Extra-anatomic if <1year
What conditions lead to SVC obstruction via intraluminal fibrosis?
indwelling catheters
PM
hypercoag state
What ar emost commonly used stents for IVC?
gianturco-Z
palmaz
SMART
wall stent
What is primary latency of stenting?
malignant 65% at 1 year
benign 75% at 1 year
how are venous tumours classified?
Infrarenal
Suprarenal (retrohepatic, infrahepatic—to RV)
Suprahepatic
How are intracaval thrombus classified?
Level I extends within 2 cm of RV
Level II extends into suprarenal IVC but below hepatic veins
Level III thrombus is to hepatic veins but below diaphragm
Level IV extends into right side of heart
What are primary venous CA?
primary leiomyosarcoma
What are secondary inferrer vena cava tumours that have thrombus
RCC most common
pheo
sarcoma
germ cell
What are symptoms of venous tumour?
abdo pain most common palpable mass lower limb edema WL Budd-chiari Fever weakness, anorexaia, night sweats (less often)
What is most useful diagnostic test for venous tumour?
CT/MR
What incision to use for infrarenal or infra hepatic tumour?
midline
What incision to sue for retrohepatic IVC replacement, or infra hepatic with wide costal margin?
bilateral subcostal
What incision for retrohepatic IVC replacement and liver resection?
right retro peritoneal (8-9)
When can you resect IVC without replacing?
if well collateralized
What adjuncts to perform when infra hepatic IVC thrombus?
divide caudate lobe veins
consider total vascular isolation (minimize blood loss)
consider venovenous bypass
When to embolize RA?
inoperable
can consider pre-op but may not shrink tumor and may increase peri-op comps
When to replace IVC?
when majority of IVC need replacement for tumor margins
what to patch IVC?
if going to be greater then 50% stenosis
How do you do retrohepatic vena cava replacement?
Total vascular isolation
Selective use of veno venous bypass for hemodynamics
Ligation of afferent and efferent lobar vasculature before prenchymal Division
What is the sequence of clamping for total vascular occlusion
Infrahepatic
Hepatic artery
Portal vein in gastrohepatic ligament
Suprahepatic
When to consider veno venou bypass?
when using total vascular occlusion to improve hemodynamics
lower complication rates
When to consider circa arrest?
thrombus level III or IV retrohepatic intrahepatic suprahepatic dz extensive reconstruction
benefit is cold schema time
