The induction of general anaesthesia and initiation of positive pressure ventilation in cases of superior vena caval (SVC) obstruction carries an unacceptably high risk of cerebral venous congestion, and with it, the risk of cerebral oedema and death. Two similar cases have been dealt with successfully in our unit: both had thyrotoxic retrosternal multinodular goitres and SVC obstruction, and both had tracheal compression mandating surgery.
Following control of the hyperthyroidism by our medical colleagues (without improvement of the symptoms of compression), the patients were submitted to surgery. The patients were fully prepared for thyroidectomy with additional exposure of their chest, abdomen and groins. Under local anaesthesia, the left internal jugular vein and the left sapheno-femoral junction were exposed and controlled. After full heparinisation, an 8 mm diameter armoured PTFE graft was anastomosed to each using 5/0 prolene sutures, the graft remaining extracorporeal. Duplex was used to insonate the ipselateral common femoral vein before and after clamp removal confirming considerably augmented venous return via the graft.
With the SVC obstruction thus considerably relieved, we enabled safe induction of general anaesthesia and positive pressure ventilation. Both patients underwent uneventful total thyroidectomy though cervical incisions alone, with minimal blood loss. The grafts were removed at the end of the procedure. Both patients recovered without mishap with compression symptoms and signs abolished.
We recommend this simple technique over the insertion of endovenous stents, which can be difficult to place satisfactorily in the presence of massive compressing goitres, in the situation of SVC obstruction caused by retrosternal goitres requiring surgery.
12 - 12 Dec 2008