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Radical excision of thymoma invading the SVC and anonymous veins

Davide Tosi1, Aldo Cannata2, Alessandro Palleschi1, Luigi Santambrogio 1

1 Fondazione Ca’ Granda Policlinico, Thoracic Surgery and Lung Transplantation Unit, Milan

2 Niguarda Great Metropolitan Hospital, Cardiac Surgery Unit, Milan

Abstract

Approximately 30% of patients with locally advanced thymoma have invasion of intra-thoracic structures precluding upfront surgery at the time of diagnosis. Actually, the evaluation of resectability is frequently based on the surgeon’s expertise, while induction chemotherapy has been used both to reduce the tumor burden and to improve disease control, even though its efficacy is discussed.

We present a case of thymoma with direct invasion of the confluence among brachiocephalic veins and superior vena cava in a 59-year old male with myasthenia gravis. The video shows the operative strategy for the radical resection of the tumor; key points were as follows:

  1. The left brachiocephalic vein resection. The rationale for sacrificing this vessel was the desire to increase the flow into the vascular prosthesis to prevent the thrombosis.
  2. Temporary shunt between right brachiocephalic vein and right atrium; this arrangement made it possible to prepare the venous bypass without any hassle.
  3. The use a reinforced PTFE graft for the venous continuity between right brachiocephalic vein and superior vena cava.

The patient had an uneventful postoperative course followed by radiotherapy and chemotherapy that completed the treatment.

In conclusion, careful planning of the operatory strategy made the radical resection of a thymoma invading great venous vessels an effective and safe procedure.