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Major vascular reconstructions in thoracic oncological surgery

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Abstract

The replacement of the superior vena cava and thoracic outlet vessels for thoracic malignancies often becomes necessary for radical oncological surgery. The pulmonary artery can be directly infiltrated by the tumor or affected by metastatic hilar lymph nodes. In some cases, it must be resected and reconstructed to achieve oncological radicality and/or avoid pneumonectomy. This study reflects a single-surgeon, retrospective experience spanning 6 years (2017–2023). We reviewed data from patients undergoing early anticoagulant therapy after superior vena cava or thoracic outlet vessels bypass and from patients undergoing early antiaggregation therapy following pulmonary artery reconstruction or resection. This series comprises 41 patients treated by a single surgeon. Fourteen patients underwent superior vena cava and thoracic outlet vessel procedures. Among these, eight patients received superior vena cava replacement (six for thymic malignancies and two for lung cancer), and six patients underwent jugular and subclavian artery/vein resection or replacement (all six had sarcomas). There was one death due to respiratory failure, not associated with bleeding or bypass closure. Additionally, there was one graft closure in a patient with severe coagulopathy and three instances of hemothorax (two patients had undiagnosed complex coagulopathies not evident in pre-operative routine blood tests). Following bleeding incidents, anticoagulation was initiated the next day in one case and based on hematological indications in the two coagulopathic patients. In the pulmonary artery series, 27 patients were involved: 20 underwent direct suture after tangential resection, and 7 received pericardial patch reconstruction. Only one case experienced bleeding necessitating redo-surgery. All these patients received early and chronic antiaggregation therapy after pulmonary artery reconstruction. We conclude that major thoracic oncological vascular surgery is safe and feasible with appropriate technical skills. However, achieving optimal results requires integration with correct early anticoagulant therapy or antiaggregation to maintain the patency of bypasses/grafts and prevent life-threatening risks associated with closure of the “new vessels.”

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  1. Thoracic Surgery Unit, IRCCS Istituto Nazionale dei Tumori Foundation, Via Venezian 1, 20133, Milan, Italy

    Leonardo Duranti & Luca Tavecchio

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  1. Leonardo Duranti
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Correspondence to Leonardo Duranti.

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Video 1: This is a case of pretreated thymoma infiltrating the superior vena cava. Here, we can observe the anastomosis between the prosthesis and the anonymous vein, as well as the anastomosis between the prosthesis and the right atrium. (MP4 177732 kb)

Video 2: This is a case of pretreated Ewing sarcoma affecting the left thoracic outlet and infiltrating the thoracic outlet vessels. In this procedure, we performed a bypass of the left subclavian artery and the left jugular vein. (MP4 212424 kb)

Video 3: Here is the autologous pericardial patch implantation and suture on the native pulmonary artery. (MP4 43579 kb)

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Duranti, L., Tavecchio, L. Major vascular reconstructions in thoracic oncological surgery. Updates Surg (2024). https://doi.org/10.1007/s13304-024-01763-0

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