Pesquisadores da Clínica Mayo Rochester, em Mineápolis, nos Estados Unidos, realizaram estudo com o propósito de avaliar o papel da reconstrução cirúrgica aberta e da endovascular em pacientes com Síndrome da Veia Cava Superior (SVCS) causada por doenças não malignas.Vinte e nove pacientes foram submetidos à reconstrução cirúrgica com 31 pontes: veia safena espiral (n=20), veia femoral superficial (n=4), aloenxerto humano (n=1) ou politetrafluoroetileno expandido (PTFEe, n=6).
Cinco falhas precoces nos enxertos, três no PTFEe e dois em enxertos de veias bifurcadas (4 tromboses e 1 estenose) foram tratadas com sucesso em revisão cirúrgica aberta. Dezessete intervenções secundárias adicionais foram realizadas em oito pacientes, 14 endovasculares e 3 cirúrgicas. A permeabilidade dos enxertos foi significativamente maior nos enxertos venosos comparados aos de PTFEe (p=0,02).
Doze intervenções endovasculares secundárias foram realizadas em seis pacientes (3 dos 3 enxertos do grupo primário, 3 dos 9 enxertos de oito pacientes do grupo secundário) para manter a permeabilidade em 11 das 12 reconstruções. Em 79% dos sintomas dos pacientes foram resolvidos ou foram reduzidos significativamente no último acompanhamento.
Os pesquisadores concluíram que o tratamento cirúrgico da SVCS benigna é efetivo a longo prazo, com intervenções endovasculares secundárias para manter a permeabilidade dos enxertos. O enxerto da veia safena espiral reta continua a ser o ducto de escolha para reconstrução cirúrgica, com resultados superiores à aqueles com veia bifurcada ou PTFEe.
Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease - Journal of Vascular Surgery
August 2003 • Volume 38 • Number 2
Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease
Manju Kalra, MBBSa [MEDLINE LOOKUP]
Peter Gloviczki, MDa* * [MEDLINE LOOKUP]
James C. Andrews, MDb [MEDLINE LOOKUP]
Kenneth J. Cherry Jr, MDa [MEDLINE LOOKUP]
Thomas C. Bower, MDa [MEDLINE LOOKUP]
Jean M. Panneton, MDa [MEDLINE LOOKUP]
Haraldur Bjarnason, MDb [MEDLINE LOOKUP]
Audra A. Noel, MDa [MEDLINE LOOKUP]
Cathy Schleck, BSc [MEDLINE LOOKUP]
William S. Harmsen, MSc [MEDLINE LOOKUP]
Linda G. Canton, RN, BSNa [MEDLINE LOOKUP]
Peter C. Pairolero, MDa [MEDLINE LOOKUP]
Objectives The purpose of this study was to evaluate the role of endovascular and open surgical reconstructions in patients with superior vena cava (SVC) syndrome caused by nonmalignant disease.
Methods Clinical data from 32 consecutive patients who underwent endovascular or open surgical reconstruction of central veins because of symptomatic benign SVC syndrome between November 1983 and June 2001 were retrospectively reviewed.
Results The study included 17 male and 15 female patients (mean age, 38 years; range, 5-69 years). Presenting symptoms were head fullness (n = 26), dyspnea or orthopnea (n = 23), headache (n = 17), or dizziness (n = 11); physical signs were head swelling (n = 31), chest wall collateral vessels (n = 29), facial cyanosis (n = 18), or arm swelling (n = 17). Etiologic factors included mediastinal fibrosis (n = 19), indwelling catheter (n = 8), idiopathic thrombosis (n = 4), or post-surgery (n = 1). Two patients were heterozygous for factor V Leiden; 1 patient had antithrombin III deficiency. Twenty-nine patients underwent surgical reconstruction with 31 bypass grafts: spiral saphenous vein (n = 20), superficial femoral vein (n = 4), human allograft (n = 1), or expanded polytetrafluoroethylene (ePTFE, n = 6). Eleven patients underwent percutaneous transluminal angioplasty or stenting; 3 primary and 8 secondary endovascular procedures were performed to treat graft stenosis (n = 7) or occlusion (n = 1). There were no early deaths. Five early graft failures in 3 ePTFE grafts and 2 bifurcated vein grafts (thrombosis, n = 4; stenosis, n = 1) were successfully treated with open surgical revision. Over a mean follow-up of 5.6 years (range, 0.4-16.6 years) in surgical patients, 17 additional secondary interventions were performed in 8 patients, 14 endovascular and 3 surgical. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were 63%, 79%, and 85%, respectively, at 1 year, and 53%, 68%, and 80%, respectively, at 5 years. Graft patency was significantly higher in vein grafts compared with ePTFE grafts (P = .02). Mean follow-up after percutaneous transluminal angioplasty or stenting was 3.1 years (range, 1 day–11.7 years). Twelve secondary endovascular interventions were performed in 6 patients (primary group, 3 of 3; secondary group, 3 of 9 grafts in 8 patients) to maintain patency in 11 of 12 reconstructions. Mean follow-up in the entire patient cohort was 5.3 years (range, 0.4-16.6 years). In 79% of patients symptoms had resolved or were significantly improved at last follow-up.
Conclusions Surgical treatment of benign SVC syndrome is effective over the long term, with secondary endovascular interventions to maintain graft patency. Straight spiral saphenous vein graft remains the conduit of choice for surgical reconstruction, with results superior to those with bifurcated vein and ePTFE. Endovascular treatment is effective over the short term, with frequent need for repeat interventions. It does not adversely affect future open surgical reconstruction and may prove to be a reasonable primary intervention in selected patients. Patients who are not suitable for or who fail endovascular intervention merit open surgical reconstruction.
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