Chap 63-65 SVC Reconstruction and Venous Tumors

Question 1

What are most common cause of SVC obstruction?

Answer 1

Non small cell

aortic aneurysm

Question 2

What are most common symptoms of SCV obstruction?

Answer 2

feelingo f fullness in head and neck
dyspnea
orthopnea
H/A
syncope visual disturbances

Question 3

What are some less frequent symptoms?

Answer 3

mental confusion
hemoptysis
dysphagia
WL

Question 4

What are signs on exam?

Answer 4

dilated neck veins
swelling of face, neck, eyelids
chest wall colaterals
arm swelling

Question 5

What is pemberton’s sign?

Answer 5

elevation of arms until the touch side of face
facial congestion and cyanosis after one minute
indicates increase intrathoracic venous P

Question 6

What are findings on CXR of SVC syndrome?

Answer 6

Mediastinal widening
Right hilar mass
Pleural effusion
Infiltrates
Dilated veins may be visible
May be normal

Question 7

What are findings on US for SVC obstruction?

Answer 7

Loss of normal variation in respiratory flow in subclavian
No change in diameter or flow with valsalva
Collaterals

Question 8

What are findings on CT/MR?

Answer 8

location of obstruction
mass/tumor
collaterals

Question 9

How do you do a venography for SVC obstruction?

Answer 9

bilat simultaneous injections of arm vein

Question 10

What are important collaterals in SVC syndrome?

Answer 10

1. azygos-hemiazygos (intercostals)
2. internal mammary (inf and superios epigastric)
3. lateral thoracoepigastric
4. vertebral and small mediastinal veins(femoral to vertebral)

Question 11

What are the type of SVC obstruction? Which is the most common?

Answer 11

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

Question 12

What are initial treatments?

Answer 12

conservative
elevation of HOB
diuresis
steroids/chemo/rad (if cancer
anticoag if cancer

Question 13

What are invasive treatments?

Answer 13

endovascular first line
stent with/out CDT
surgical

Question 14

How many patients resolve with chemo/rad?

Answer 14

80% in 4 weeks

Question 15

what are indications for intervention for SVC obstruction?

Answer 15

indication incapacitating symptoms that cannot be alleviated by conservative measures

III and IV usually not candidates for endovascular

failure of endovascular

Question 16

What is surgical option for SVC obstruction?

Answer 16

jugular/innominate to femoral vein/RA bypass with
SVG
femoral vein
spiral saphenous
ePTFE

Question 17

What are surgical approaches?

Answer 17

Mediastinal reconstruction if life expectancy > 1year

Extra-anatomic if <1year

Question 18

What conditions lead to SVC obstruction via intraluminal fibrosis?

Answer 18

indwelling catheters
PM
hypercoag state

Question 19

What ar emost commonly used stents for IVC?

Answer 19

gianturco-Z
palmaz
SMART
wall stent

Question 20

What is primary latency of stenting?

Answer 20

malignant 65% at 1 year

benign 75% at 1 year

Question 21

how are venous tumours classified?

Answer 21

Infrarenal
Suprarenal (retrohepatic, infrahepatic—to RV)
Suprahepatic

Question 22

How are intracaval thrombus classified?

Answer 22

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

Question 23

What are primary venous CA?

Answer 23

primary leiomyosarcoma

Question 24

What are secondary inferrer vena cava tumours that have thrombus

Answer 24

RCC most common
pheo
sarcoma
germ cell

Question 25

What are symptoms of venous tumour?

Answer 25

``` abdo pain most common palpable mass lower limb edema WL Budd-chiari Fever weakness, anorexaia, night sweats (less often) ```

Question 26

What is most useful diagnostic test for venous tumour?

Answer 26

CT/MR

Question 27

What incision to use for infrarenal or infra hepatic tumour?

Answer 27

midline

Question 28

What incision to sue for retrohepatic IVC replacement, or infra hepatic with wide costal margin?

Answer 28

bilateral subcostal

Question 29

What incision for retrohepatic IVC replacement and liver resection?

Answer 29

right retro peritoneal (8-9)

Question 30

When can you resect IVC without replacing?

Answer 30

if well collateralized

Question 31

What adjuncts to perform when infra hepatic IVC thrombus?

Answer 31

divide caudate lobe veins consider total vascular isolation (minimize blood loss) consider venovenous bypass

Question 32

When to embolize RA?

Answer 32

inoperable | can consider pre-op but may not shrink tumor and may increase peri-op comps

Question 33

When to replace IVC?

Answer 33

when majority of IVC need replacement for tumor margins

Question 34

what to patch IVC?

Answer 34

if going to be greater then 50% stenosis

Question 35

How do you do retrohepatic vena cava replacement?

Answer 35

Total vascular isolation Selective use of veno venous bypass for hemodynamics Ligation of afferent and efferent lobar vasculature before prenchymal Division

Question 36

What is the sequence of clamping for total vascular occlusion

Answer 36

Infrahepatic Hepatic artery Portal vein in gastrohepatic ligament Suprahepatic

Question 37

When to consider veno venou bypass?

Answer 37

when using total vascular occlusion to improve hemodynamics lower complication rates

Question 38

When to consider circa arrest?

Answer 38

``` thrombus level III or IV retrohepatic intrahepatic suprahepatic dz extensive reconstruction ``` benefit is cold schema time