Commentary: Rational decision making for a rare case

Central MessageThe authors exhibit rational decision making to guide the surgical management of a rare condition.See Article page 183 in the December 2020 issue. The authors exhibit rational decision making to guide the surgical management of a rare condition. See Article page 183 in the December 2020 issue. Arterial thoracic aneurysms are much more common than venous thoracic aneurysms. Even what constitutes a venous aneurysm remains controversial, and there remains no universally accepted size criteria. Superior vena cava (SVC) aneurysms have been described fewer than 50 times in the literature. The majority of cases are fusiform aneurysms found incidentally as mediastinal widening on chest X-ray. These are most often managed conservatively with serial imaging and selective antithrombotic therapy to prevent thromboembolic complications. Honda and colleagues provide a step-by-step description of their successful management of a rapidly expanding SVC aneurysm.1Honda K. Yuzaki M. Fujimoto T. Nishimura Y. Reconstruction of the superior vena cava with an autologous pericardial patch for a giant superior vena cava aneurysm.J Thorac Cardiovasc Surg Tech. 2020; 4: 183-186Google Scholar The patient in question presented clinically with syncope and on investigation was found to have a saccular SVC aneurysm with associated pulmonary embolism. The etiology of the syncope is unclear in this case, but it is likely related to impaired left ventricular filling and subsequent diminished cardiac output. Known clinical sequelae of SVC aneurysms include pulmonary embolism, symptoms related to compression of surrounding structures, and rupture. The patient's aneurysm was large, and generally speaking, saccular aneurysms are associated with a greater risk of rupture than fusiform aneurysms. However, unlike for aortic aneurysms, for SVC aneurysms there is insufficient experience on which to base a precise size threshold for surgical replacement. As such, the patient was appropriately managed conservatively with watchful waiting and oral anticoagulation. By 6 months, the aneurysm exhibited “rapid expansion,” and the decision was made to surgically correct the SVC to prevent further expansion and rupture. In a literature review of 19 cases of SVC aneurysm, 11 were managed conservatively with no complications, and the other 8 were managed operatively.2Calligaro K.D. Ahmad S. Dandora R. Dougherty M.J. Savarese R.P. Doerr K.J. et al.Venous aneurysms: surgical indications and review of the literature.Surgery. 1995; 117: 1-6Abstract Full Text PDF PubMed Scopus (206) Google Scholar The reasons for operative intervention were evenly divided between treating symptoms (eg, dyspnea, chest pain, contained rupture) and preventing complications (eg, risk of rupture due to expanding size). The surgical workup included anatomic assessment with repeat computed tomography scan and aortography. This allowed the team to create an effective procedural plan and to rule out arteriovenous fistula. The authors shared decision making with the patient, who was averse to the use of xenogeneic material such as bovine pericardium, which is commonly used to patch vascular structures and cardiac defects. Autologous pericardium was chosen; other possible options were Teflon, Dacron, and an autologous vein patch. Controversy remains as to the ideal patch material for venous, arterial,3Muto A. Nishibe T. Dardik H. Dardik A. Patches for carotid artery endarterectomy: current materials and prospects.J Vasc Surg. 2009; 50: 206-213Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar and intracardiac repairs.4Us M.H. Sungun M. Sanioglu S. Pocan S. Cebeci B.S. Ogus T. et al.A retrospective comparison of bovine pericardium and polytetrafluoroethylene patch for closure of ventricular septal defects.J Int Med Res. 2004; 32: 218-221Crossref PubMed Scopus (29) Google Scholar Finally, from an operative standpoint, the authors used an on-pump approach. The advantages of this approach are the ability to isolate the aneurysmal segment using snares or clamps, fillet open the aneurysm to inspect the tissues, scavenge blood, obtain controlled hypothermia, facilitate the potential for circulatory arrest, remove any thrombus, and patch-repair the SVC. Yet another approach is off-pump ligation at the aneurysm stalk or aneurysmectomy.5Gozdziuk K. Czekajska-Chehab E. Wrona A. Tomaszewski A. Drop A. Saccular aneurysm of the superior vena cava detected by computed tomography and successfully treated with surgery.Ann Thorac Surg. 2004; 78: e94-e95Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,6Janczak D. Skiba J. Gemel M. Mak M. Ziomek A. Malinowski M. et al.Giant saccular superior vena cava aneurysm—a rare and difficult clinical case.J Thorac Dis. 2016; 8: E247-E249Crossref PubMed Scopus (11) Google Scholar The authors exemplified rational decision making in their management of this rare condition. Adhering to the principle of “first, do no harm,” they chose conservative management with watchful waiting in the absence of compelling data to the contrary. Expansion of the aneurysm forced their hand to intervene surgically, and they proceeded as safely as possible by ruling out devastating complications preoperatively and using cardiopulmonary bypass to reduce the risks of the operation. Finally, they prioritized patient preference, an important principle in the management of rare conditions when clinical evidence is sparse.7Day S. Evidence-based medicine and rare diseases.in: Posada de la Paz M. Groft S.C. Rare Diseases Epidemiology. Springer, New York2010: 41-53Crossref Scopus (7) Google Scholar Reconstruction of the superior vena cava with an autologous pericardial patch for a giant superior vena cava aneurysmJTCVS TechniquesVol. 4PreviewA 54-year-old man was transported to our hospital as the result of a loss of consciousness. Emergent enhanced computed tomography (CT) revealed a large superior vena cava (SVC) aneurysm (62 × 92 × 72 mm) and pulmonary thromboembolism. As the patient was hemodynamically stable, prudent follow-up with anticoagulant therapy was performed. During the follow-up, thromboembolism of the pulmonary artery improved; however, chest radiography performed 6 months after admission showed an enlarged SVC shadow (Figure 1, A and B). Full-Text PDF Open Access

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