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Cite this article as: Ali JM, Dunning J. Stented CorMatrixV conduit to bypass benign superior vena caval obstruction. Eur J Cardiothorac Surg 2017; doi:10.1093/ejcts/
ezx303.
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Stented CorMatrixV conduit to bypass benign
superior vena caval obstruction
Jason M. Ali* and John Dunning
Department of Cardiothoracic Surgery, Papworth Hospital Foundation NHS Trust, Papworth Everard, Cambridge, UK
* Corresponding author. Department of Cardiothoracic Surgery, Papworth Hospital Foundation NHS Trust, Papworth Everard, Cambridge CB23 3RE, UK. Tel: +441480-830541;
fax: +44-1480-364332; e-mail: ja297@cam.ac.uk (J.M. Ali).
Received 18 May 2017; received in revised form 24 July 2017; accepted 30 July 2017
Abstract
Surgical venous bypass is an effective treatment option in the management of benign superior vena caval obstruction. Here, we present
CorMatrixV as a novel conduit choice, supported internally by an endovascular stent in an attempt to prevent stenosis and reduce reintervention rate following surgical bypass.
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Keywords: CorMatrix • Superior vena caval obstruction • Surgical bypass
INTRODUCTION
Superior vena cava (SVC) syndrome results from SVC obstruction.
An intrathoracic malignancy causing extrinsic compression or SVC
invasion is responsible for many cases. The remainder results from
non-malignant disorders, such as venous thrombosis and fibrosis,
secondary to indwelling catheters or pacing leads, post-radiation
fibrosis, fibrosing mediastinitis associated with infections and
Budd–Chiari syndrome [1, 2]. Although endovenous stenting has
become a first-line treatment option, complications are reported
in up to 7% of cases including infection, pulmonary embolism,
stent migration, reocclusion and SVC perforation [2]. Furthermore,
not all cases are suitable for stenting. Surgical venous bypass is an
alternative approach that has proved effective in alleviating venous
congestion. Here, we report a novel approach creating a stented
synthetic conduit with CorMatrixV (CorMatrix, Atlanta, GA, USA).
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TECHNIQUE
The operation is performed through a median sternotomy. On
opening the pericardium, the SVC can be visualized and the
pathology assessed (Fig. 1A).
The CorMatrix conduit is first created. The required length of
the conduit should be measured, and an appropriately sized
sheet of the CorMatrix should be sutured along its length to create the tube graft. The diameter of the tube is determined by the
size of the stent (Fig. 1B), which is chosen based on the size of
the cavoatrial junction.
The patient is then heparinized and cardiopulmonary bypass is
instituted with standard aorto-right atrial cannulation. The confluence of the great veins is mobilized at the root of the right neck,
and the veins opened at this level to form a common circumference. The conduit can now be sutured directly end-to-end to the
confluence of the veins using continuous 5-0 Prolene suture.
Cardiotomy suction catheters are placed in the neck veins during
formation of the anastomosis to give a bloodless operating field.
A clamp can then be applied across the conduit to confirm patency and ensure haemostasis of the proximal anastomosis.
Having confirmed this, the right atrial appendage is clamped and
the tip amputated. An end-to-end anastomosis is then fashioned
between the conduit and the atrial appendage using 5-0 Prolene
suture. Before suturing, trabeculae are divided inside the atrial
appendage to ensure there is no obstruction to drainage. The
clamp across the conduit can then be removed, and an immediate reduction in central venous pressure should be observed.
To reduce the risk for subsequent stenosis, an appropriately sized
Zilver-VenaTM venous self-expanding stent (Cook Medical Inc.,
Bloomington, IN, USA) is finally placed through the conduit across
both suture lines. A purse string is placed in the atrial free wall with a
small stab incision to allow for the insertion of the stent deployment
device (Fig. 1C). The stent position should be confirmed visually, and
a Prolene suture is placed to prevent stent migration (Fig. 1D).
The patient can then be weaned from cardiopulmonary bypass
and transferred to critical care. Anticoagulation with warfarin is
commenced postoperatively with a target international normalized ratio of 2.5 for 3 months.
To date, we have performed this procedure in 5 patients. The
operative photographs are from a case of fibrosing mediastinitis
secondary to a histoplasmosis infection successfully treated with
this technique (Fig. 2). In our series, there have been no episodes
of stenosis or thrombosis, or any patients requiring reintervention,
with a median follow-up of 16 months. This is now the agreed
technique for SVC bypass performed at our centre.
C The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
European Journal of Cardio-Thoracic Surgery 0 (2017) 1–3
doi:10.1093/ejcts/ezx303
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J.M. Ali and J. Dunning / European Journal of Cardio-Thoracic Surgery
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Figure 1: Intraoperative photographs (A) at the site of the fibrotic occluded section of the superior vena cava (asterisk); (B) of the CorMatrixV tube graft created by
suturing a measured piece of matrix; (C) following completion of the anastomoses, where a stent is deployed via an introducer placed through the atrium and (D) the
final appearance of the stented CorMatrix tube bypass graft.
Figure 2: (A) Preoperative cross-sectional imaging investigations confirming the superior vena cava (SVC) occlusion and the presence of venous collaterals. Coronal
magnetic resonance image demonstrating the SVC occlusion between the brachiocephalic confluence and the atrium (arrow) and a transverse computed tomography
image confirming occlusion, fibrosis and peripheral calcification (arrow). (B) Postoperative imaging confirming patency of graft. A non-contrast image demonstrates
the stent (arrow) and a contrast-enhanced image confirms widely patent graft (arrow).
Comments
Although endovascular intervention has become the first-line
treatment option in the management of patients with SVC obstruction, surgical bypass continues to have a role in situations
where endovascular treatments have failed or are not possible
[2, 3]. There is no consensus on the optimal conduit material to
perform the bypass, and a variety of both autologous and synthetic materials have been described [3]. A 3-year primary patency rate of 65.3% has been reported for surgical bypass, which
compares favourably to endovascular treatments for which the
pooled patency rate was 48% [3]. Notably, 28.4% required reintervention for stenosis or thrombosis.
Here, we present the CorMatrix as an alternative conduit
choice, supported internally by an endovascular stent in an attempt to prevent the late compression, fibrosis and occlusion
from which other conduits suffer. The CorMatrix is a decellularized extracellular matrix from porcine small intestinal submucosa, which is a widely used biological tissue substitute [4].
Animal models and human studies have confirmed that
CorMatrix is an effective vascular conduit that has been used for
the reconstruction of a range of tissues such as abdominal wall,
bladder wall and urethra and that has been applied for a range
of uses in congenital cardiac surgery [4]. Animal model studies
have found that CorMatrix is effective as a vascular conduit.
Histological examination of the conduits at various time points
revealed collagen deposition, formation of neocapillaries and
fibrocellular neointima, endothelialization of the graft without
calcification and the potential for remodelling which has facilitated its use in congenital cardiac surgery as pulmonary artery
3
and aortic grafts with good outcomes. Histological analysis at
late time points in clinical series has confirmed that the recellularization observed in animal studies does occur in humans and
reveals a similar histological organization of the cell reconstitution, with intima, media and adventitia, as observed in the native arteries [4].
With these findings, we were encouraged to utilize the
CorMatrix as a conduit material in patients with SVC obstruction.
In view of the rates of stenosis and reintervention reported with
other conduits, we elect to stent the tube graft at the time of surgery to maximize long-term patency. Furthermore, the incidence
of graft thrombosis prompted us to electively anticoagulate patients with warfarin for 3 months.
Conflict of interest: none declared.
REFERENCES
[1]
[2]
[3]
[4]
Yellin A, Rosen A, Reichert N, Lieberman Y. Superior vena cava syndrome. The myth—the facts. Am Rev Respir Dis 1990;141:1114–8.
Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena
cava syndrome with malignant causes. N Engl J Med 2007;356:1862–9.
Sfyroeras GS, Antonopoulos CN, Mantas G, Moulakakis KG, Kakisis JD,
Brountzos E et al. A review of open and endovascular treatment of superior vena cava syndrome of Benign Aetiology. Eur J Vasc Endovasc
Surg 2017;53:238–54.
Hibino N, McConnell P, Shinoka T, Malik M, Galantowicz M. Preliminary
experience in the use of an extracellular matrix (CorMatrix) as a
tube graft: word of caution. Semin Thorac Cardiovasc Surg 2015;27:
288–95.
SURGICAL TECHNIQUE
J.M. Ali and J. Dunning / European Journal of Cardio-Thoracic Surgery
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