SURGERY OF THE SUPERIOR VENA CAVA: RESECTION AND RECONSTRUCTION 



Patient Selection 

Operative Steps 

Preference Card 

Tips and Pitfalls 

Results 

FAQs


Patient Selection 

Resection and reconstruction of the superior vena cava (SVC) is still considered a surgical challenge; the numerous problems related to patient selection, choice of the appropriate surgical strategy and technique, the most suitable material for replacement, and the number of potential complications definitely show an impact on prognosis. However, with the appropriate indications and surgical technique a clear benefit has been documented in a selected group of patients.

The anatomy of the SVC (Figure 1) and left brachiocephalic vein put this venous system in a critical area vulnerable to tumors arising both in the lung and anterior mediastinum. Malignant invasion is the most frequent indication for SVC resection and reconstruction. Lung cancer can involve the vessel with direct invasion by primary tumors arising in the right upper lobe or by nodal metastases (stations R2, R4 and 3) (Figure 2). Anterior mediastinal tumors (thymoma, thymic carcinoma, germ cell tumors, etc) may involve directly both the SVC and the left brachiocephalic vein (Figure 3). Primary tumors of the SVC represent a rare indication for surgery. Other infrequent indications are saccular aneurysms or primary malformations and traumatic lesions (iatrogenic, blunt, or penetrating injuries).


Figure 1. Schematic anatomy of the superior vena cava. 



Figure 2A & B. (A) Lung cancer invading the superior vena cava. (B) Mediastinal lymph nodes invading the superior vena cava. 

Figure 3. Cortical thymoma invading the superior vena cava. 



Contraindications to surgical resection and replacement include the presence of SVC syndrome related to unresectable tumors, a completely obstructed SVC with a rich collateral vein circulation and abnormal walls of the proximal vein(s) (i.e., tumor involvement at the margins); particular attention needs to be directed to patients undergoing induction chemo-radiotherapy.


Figure 4. Superior vena cavography showing obstruction by a mediastinal tumor. 

The preoperative work–up should always include total body CT scan for patients with lung cancer or tumors of the mediastinum. Other specific investigations should be tailored according to the histological diagnosis. Superior vena cavography should be performed when SVC invasion is suspected (Figure 4). Alternatively, magnetic resonance imaging can help to define the site and extension of the infiltration and the presence of thrombosis, and anatomical variations of the SVC system can be revealed. Echocardiography should be routinely included to rule out extension of a thrombus into the right atrium. Brain CT scan with contrast injection should always be performed for staging purposes (lung cancer) and also to rule out the presence of any brain disease that may be exacerbated by CNS edema during SVC clamping.

A careful functional evaluation should be performed (PFTs and arterial blood gas analysis) since a relevant number of patients with right upper lobe lung cancer invading the SVC are candidates for standard pneumonectomy or pneumonectomy with carinal resection.


Operative Steps 

Surgical Approach

A right thoracotomy in the 4th or 5th intercostal space is the standard approach for upper lobe tumors invading the SVC. Complete median sternotomy is recommended for tumors of the anterior mediastinum. Both approaches allow optimal exposure of the operatory field; through the right thoracotomy we have easy access to the lung parenchima, the SVC, the trachea, the pulmonary hilum and right atrium; however, through this approach it is more difficult to control the left brachiocephalic vein. Median sternotomy allows a wide exposure of the mediastinum and the dissection can be easily extended into the neck. This approach can be turned into a “trap door incision” if a more comfortable exposure of the right lung and subclavian vessels is required.

Intraoperative management: Resection and reconstruction of the SVC is considered a major technical challenge due to the potential detrimental effects of clamping a patent vessel. Partial caval clamping or clamping a chronically obstructed SVC is generally well tolerated; on the other hand, occlusion of a patent SVC may produce intracranial bleeding, brain edema and damage, and a potentially lethal reduction of cardiac output. These complications can be avoided by careful patient selection and intraoperative monitoring and management.

A double lumen endobronchial tube is placed to achieve one–lung ventilation. A radial arterial line and a venous line in the internal jugular vein are inserted routinely to obtain continuous pressure monitoring. Two additional venous lines are placed in the lower limbs to achieve volume expansion during venous clamping.

A Foley catheter is inserted to monitor urine output. EKG monitoring is obviously mandatory. Transesophageal echo is optional as well as nasogastric tube placement; the latter may be of help as an anatomical marker during dissection for lung cancer extensively involving the mediastinum.

Closure of up to 50% of the SVC circumference can be performed without any hemodynamic imbalance. In patients with tight or complete obstruction of the vessel venous clamping does not significantly modify cerebral circulation and cardiac output. In both cases the duration of venous clamping is not a limiting factor and the operation can be safely performed without feeling stressed by the potential length of the reconstructive step. During complete clamping of the unobstructed SVC, there is a clear hemodynamic derangement with an increase of the mean venous pressure in the cephalic districts and a decrease in mean arterial pressure with a consequent reduced brain arterial–venous gradient. This may lead to brain edema, hemorrhage and dysfunction (usually transient). These hemodynamic modifications are evident in the entire cephalic distribution. For this reason, a cyanotic facies is almost always present during SVC clamping; however, it is usually completely reversible after declamping. Petechiae may be evident in the immediate postoperative period and disappear within a couple of weeks after surgery.

The hemodynamic imbalance is reduced with an aggressive intraoperative management by the anesthetist, along with some technical tricks.

Fluid implementation and pharmacological agents: this strategy is devoted to increase venous return and maintain the normal arterial–venous gradient in the brain. Macromolecules, blood and plasma should be used. Vasoconstrictive agents are indicated to increase the mean arterial pressure. At the end of the procedure diuretics are administered to reduce edema in the cephalic regions. Anticoagulation therapy is mandatory during and immediately after the operation: intravenous sodium heparin (0.5 mg/Kg) is given before clamping and continued during the immediate postoperative period (adjust heparin dose to achieve INR = 2 to 2.5). It is usually switched to warfarin agents at the time of discharge.



Surgical strategy and shunting techniques: Every effort should be attempted to reduce clamping time as much as possible, in particular when the SVC system is not completely occluded before the operation. 
Figure 5A & B. (A) Intraluminal shunt. (B) Extraluminal shunt during reconstruction of the superior vena cava. 

It has been reported that up to 45 to 60 minutes of complete clamping is usually tolerated with the appropriate pharmacological support. For lung cancer resection, the vascular step should be always performed before any other reconstructive procedure of the airway. For mediastinal tumors involving the upper lobes, the dissection should be performed from the left to the right side; the right part of the excision is usually performed after vascular reconstruction, in particular when a lobectomy is required. Intravascular or extravascular shunts (Figure 5) may be used to reduce the effects of vascular clamping during resection and reconstruction of the SVC. However, thrombosis of the shunt may occur; furthermore, these devices occupy space in the operative field making the anastomosis more difficult. 
Surgical Technique


Figure 6. Tangential resection of the superior vena cava with direct suture. 


Figure 7. Reconstruction of the superior vena cava and left brachiocephalic vein with a patch of autologous pericardium. 

Tangential resection and venous plasty: in cases in which less than 30% of the SVC circumference is involved, a partial resection of the vessel can be performed. For minimal invasion, a tangential resection of the defect closed with a running suture or a vascular stapler is usually easy and leaves a patent vessel (Figure 6). Larger defects, especially if they are longitudinally extensive, require reconstruction; this can be obtained by the interposition of a patch of autologous or bovine pericardium (Figure 7). Autologous pericardium may be fixed in diluted glutaraldehyde (two drops of 20% glutaraldehyde in 50 cc of saline) for one minute to let it stiffen and facilitate manipulation during suturing.


Figure 8. Reconstruction of the superior vena cava with a PTFE graft. 


Figure 9. Reconstruction of the superior vena cava with a patch of autologous pericardium associated with a right upper sleeve lobectomy. 

SVC replacement: replacement of the whole body of the SVC is the most frequent type of reconstruction (Figure 8). In patients with lung cancer, it is usually associated with right upper lobectomy or pneumonectomy; however, SVC reconstruction may be required during carinal pneumonectomy, sleeve lobectomy (Figure 9), and reconstructive procedures of the pulmonary artery[5]; the latter two should always be attempted if they help to avoid pneumonectomy. SVC replacement requires a tumor–free confluence of both brachiocephalic veins. The reconstruction is usually performed using a straight non-ringed PTFE graft (18 – 20 mm). An autologous or bovine pericardial tube could also be used (Figure 10). After proximal and distal clamping, the SVC is excised. The proximal anastomosis is performed first, using a 5-0 polypropylene suture, starting from the posterior aspect of the prosthesis or the tube of pericardium. The distal anastomosis is subsequently performed with the same technique. Before tying the distal suture line, the proximal clamp is gently released and deaeration is performed; afterwards, the distal clamp is released and knots are tied. After complete filling of the graft by blood, there should be no tension of the suture lines or torsion or kinking.


Figure 10A & B. (A) Reconstruction of the superior vena cava with a tube of bovine pericardium. (B) Construction of the tube of pericardium over a 10 ml syringe. 


Figure 11A & B. (A) Isolated reconstruction of the right brachiocephalic vein. (B) Isolated reconstruction of the left brachiocephalic vein. 


Figure 12. Reconstruction of the left brachiocephalic vein using a ringed PTFE graft. 

Figure 13. Simultaneous reconstruction of the right and left brachiocephalic system. 

Sometimes it may be indicated to replace only one brachiocephalic vein (either the right or left, according to local invasion). A ringed PTFE graft should be used (Figure 11, 12), especially for the left vessel and the distal anastomosis should be performed on the inferior stump of the SVC or on the right atrium. Use of the auricle should be avoided because of the presence of the pectinate muscles. In this situation, the prosthesis may be too long after closure of median sternotomy and could kink easily. Also postoperative mediastinal fibrosis (especially if radiotherapy is administered) could contribute to graft compression. Simultaneous revascularization of both brachiocephalic veins (Figure 13) is rarely required since there are enough anastomotic venous communications in the neck. Revascularization of both systems is indicated in case of previous neck surgery (laryngeal or thyroid surgery for cancer); a separate distal anastomosis of the two grafts is preferred to avoid thrombosis of the accessory left limb of a Y graft, starting at the level of the graft–to–graft anastomosis.

Palliative bypass: the indications for palliative procedures of bypass are extremely rare due to the low venous blood flow obtained from the axillary or jugular veins. Surgically created A–V fistulae devoted to increase flow through the bypass conduit are generally unsuccessful.


Preference Card 

2.5 magnification loupes 
Headlight 
Long (24 cm) heavy titanium Castro–Viejo needle holder when performing the vascular sutures through lateral thoracotomy; standard Castro–Viejo needle holder when working through median sternotomy. 
Straight ringed and unringed PTFE grafts (from 12 mm to 20 mm) 
Bovine pericardium 
Glutaraldehyde (two drops of 20% glutaraldehyde in 50 ml of saline) 
Vascular shunts 



Tips and Pitfalls 

Carefully select candidates for SVC resection and reconstruction. 
Never deny this procedure to patients who correctly fit all the indications, but don’t hesitate to avoid surgery when contraindications are present. Don’t be attracted by the chance to perform a technically demanding operation. 
Patients with primary tumors of the mediastinum are excellent candidates; after radical resection, long-term survival is extremely encouraging. 
Patients with N2 lung cancer are not ideal candidates from the oncological point of view; no long-term survivors have been reported. Also, incomplete resection is considered a negative prognostic factor. 
Avoid SVC resection and revascularization in patients with excellent collateralization towards the inferior vena cava. 
Do not dissect too much of the SVC and the two brachiocephalic veins on the side of the proximal anastomosis; you need just enough space to clamp the vessel and perform the anastomosis. Excessive mobilization could favor twisting and stenosis of the proximal suture line. 
Choose the appropriate graft size to allow optimal flow (18 mm to 20 mm for replacement of the body of the SVC, 12 mm to 13 mm for the left brachiocephalic vein, 12 mm to 14 mm for the right brachiocephalic vein). 
Choose the appropriate length of the graft to avoid kinking, especially when replacement of the left brachiocephalic vein is performed through a median sternotomy. 
Heparinization is mandatory as in every vascular reconstruction. 
When reconstructive surgery of the airway is part of the operative procedure, always avoid contamination of the vascular surgical field. The SVC and tracheal suture lines should be separated by interposing a pedicled graft (intercostal muscle). 


Results 

A number of potential complications may be associated with resection and reconstruction of the SVC. Anastomotic stenosis may occur both at the level of the proximal and distal suture lines. Early diagnosis is extremely important; for this reason, a postoperative angiogram or MR should always be performed before discharge. Proximal kinking is the most frequent cause of stenosis; this may be due to excessive dissection and mobilization, especially if the left brachiocephalic vein is reconstructed through a median sternotomy. Also, excessive length of the graft may cause kinking. Management of this complication includes surgical correction in the early postoperative period and dilation and stenting when it is diagnosed later.

Other potential complications are graft thrombosis and infection. The former usually occurs early after the operation and may cause acute SVC syndrome. Graft infection is a serious complication and occurs more frequently when the vascular reconstruction is associated with major airway surgery (tracheal or bronchial sleeve resections). Conservative management of this complication is possible when the patient is not septic. In case of septicemia, the graft should be removed, possibly after progressive clamping of the prosthesis through an open window, as described by other authors.

Operative mortality should be between 5% and 10%. The survival rate after radical resection of mediastinal tumors invading the SVC is excellent: 60% at 5 years according to Dartevelle and colleagues. Patients with lung cancer show a less favorable prognosis: about 30% at five years. There are no long-term survivors among patients with N2 disease; the potential role of induction chemotherapy in this group of patients is still to be defined.

FAQs

1. Which patients will be candidate for prosthetic replacement of the superior vena cava (SVC)?
2. What types of materials are available for replacing the SVC?
3. Which are the preoperative investigations that each patient with suspected SVC invasion should have?
4. Which is the intraoperative monitoring?
5. What kind of surgical approach should be used?
6. How prevent the hemodynamical effects of SVC clampage?
7. Which types of SVC reconstruction can be done?
8. Are palliative SVC by-pass(es) justified?
9. How anticoagulate the patient?
10. Which are the complications of SVC revascularization?

 
   

1.

Which patients will be candidate for prosthetic replacement of the superior vena cava (SVC)?
SVC resection and revascularization is most commonly indicated for completely resecting mediastinal and, less frequently, bronchogenic tumors. While for mediastinal tumors of whatever histology, SVC resection and revascularization can be curative, th e indications for non-small cell bronchogenic tumors are rare since they depend on whether or not the SVC is invaded by the tumor itself or by superior mediastinal lymph nodes. In this last circumstance, prognosis is poor and surgery not justified.

SVC syndromes related to unresectable bronchogenic tumors should not be considered for SVC revascularization and internal jugular to right atrium or extra-anatomical by-pass(es) are not earned. Indications for palliative SVC procedures are exc eptional and might be evoked for slow-growing diseases, e.g. mediastinal primary or secondary fibrosis or SVC thrombosis of unknown etiology. Postoperative graft thrombosis is at risk and can have serious consequences in terms of pulmonary embolism. In this sense, the status of the cephalic venous collateral pathway plays a major role. Since the proximal anastomosis needs to be performed either at the origin of the SVC or at the level of one or both brachiocephalic veins, SVC revascularization can be made only if there is an excellent patency at the level of the cephalic venous bed. Moreover, the proximal veins should have normal walls.

Obstructed SVC usually present a rich collateral venous circulation which can be competitive and re duce the flow through the graft. Indications in this situation should be individually evaluated to avoid graft thrombosis.

Primary angiosarcomas or leiomyosarcomas of the SVC are rare, usually asymptomatic and along with congenital aneurysms are other indications.

Further indications include iatrogenic, blunt or penetrating injuries. Iatrogenic SVC thrombosis that may require prosthetic replacement may be caused by prolonged Swan-Ganz, endocardial pacing and central venous catheters . Thoracic blunt trauma or disinsertion of the brachiocephalic veins during sternotomy are other rare causes, as well as Behçet disease.
 
   

2.

What types of materials are available for replacing the SVC?
The currently available materials for SVC reconstruction include spiral saphenous vein, free pericardial and polytetrafluoroethylene (PTFE) grafts. The major drawbacks of the first two are the requirement of an intraoperative time-consuming modeling and their potential compression induced by postoperative and radiation-induced fibrosis. Among the different vascular prostheses, PTFE graft is the only material remaining patent as a venous substitute because a neointima will growth on its internal wall. Its easy surgical manipulation over other autologous materials makes it the material of choice of SVC reconstruction.
 
   

3.

Which are the preoperative investigations that each patient with suspected SVC invasion should have?
A preoperative work-up evaluating the extension of the primary disease should be performed routinely. All patients should have a superior vena cavography (simultaneous injection through both upper limbs) before operation to delineate the site and ex tension of the venous obstruction, presence of possible proximal thrombosis and to anticipate where the proximal graft anastomosis can be made. Echocardiography eliminates thrombosis extension into the right atrium and appreciates the patency of the jugular and axillary veins. Since a majority of patients with bronchogenic cancer may present with a clinically and radiologically silent SVC invasion, computer tomography (CT) of the thorax and pulmonary angiography are diagnostic; typically, t hese tumors arise from the ventral segment of the right upper lobe and invade the right mediastinal artery (angiography) and the posterior aspect of the SVC (contrast CT). Brain CT scan should always be performed to eliminate brain diseases which ma y increase brain edema during SVC clamping.
 
   

4.

Which is the intraoperative monitoring?
Apart from the routine anesthetic procedures required for every major pulmonary resection procedure, pertinent to the SVC procedure are:
  
i. double-lumen tube to obtain one-lung ventilation;
ii. continuous arterial and venous pressure measurements to monitor the drop of the systemic pressure caused by the reduced venous return to the right heart during venous clamping;
iii. a cephalic vein catheter placed in the forearm or more proximally in the antecubital fossa or into the right internal jugular vein to monitor the venous pressure in the cephalic territory;
iv. foley catheter to monitor urine output;
v. electrocardiographic monitoring limb or chest limbs to monitor cardiac electrophysiological alterations during venous clamping, si nce the distal clamp may be too close to the sinus node. At least two venous lines should be placed in the lower limbs to achieve volume expansion during venous clamping.

Transient cyanotic faces during SVC clamping are reversible after venous declamping. Facies petechiae may develop but are usually transient and disappear after 1 to 2 weeks after the operation.
 
   

5.

What kind of surgical approach should be used?
The usual approach include a right thoracotomy in the fifth intercostal space for bronchogenic tumors and a median sternotomy for tumors originating from the anterior compartment of the mediastinum, respectively. Median sternotomy allows a large expo sure of the entire anterior mediastinum, right atrium, both brachiocephalic veins and the SVC on their entire lengths and can be easily extended to the neck. The right thoracotomy has the best exposure of the right hilum, SVC and right atrium but ren ders dissection, control and revascularization of the left brachiocephalic vein demanding.
 
   

6.

How prevent the hemodynamical effects of SVC clampage?

The effects of SVC clampage are different according to the degree of obstruction of the SVC. For patients whose SVC is completely obstructed or tightly stenosed, intraoperative venous clamping results in a negligible hemodynamical compromise since a functioning collateral venous network already exists and supplements the flow obstruction to the SVC. By contrast, when the intrathoracic or mediastinal disease does not obstruct the SVC, an even sharp venous clamping might induce an hemodynamicall y cascade of events including decreased cardiac inflow and outflow, increased venous pressure of the cephalic territory and alterations of the cerebral arterial-venous gradient leading to brain damage and intracranial bleeding.

For patients wi th SVC obstruction or tight SVC stenosis, venous clamping does not significantly modify cardiac output and cerebral circulation. Consequently, the duration of venous clamping is not a limiting factor and the operation can be carried out safely and routinely without taking into account the reconstructive SVC step. By contrast, for patients with nonobstructed SVC, venous clamping is associated with an hemodynamic compromise resulting in decreased cardiac output and increased venous pressure in the cephalic territory which may induce brain damage.

Several tools may mitigate this hemodynamic compromise in unobstructed SVC. i) Shunt procedures: intraluminal shunting of the blood from the brachiocephalic vein into the right atrium may re duce the hemodynamic consequences of venous clamping. However, whatever the type of shunt utilized, their major drawbacks are their potential thrombosis and that they fill the operative field making the performance of the distal anastomosis difficul t. ii) Pharmacological agents and fluid implementation: they should increase the venous blood return to the right atrium and maintain the physiological arterial-venous gradient in the cerebral territory. The first target is achieved by an adequate co mpensation of all blood losses by blood components and macromolecules. Since the cranial venous pressure may rise up to 40 mm Hg during venous clamping, maintenance of the cerebral arterial-venous gradient requires fluid administration (average 15- 20 mL/Kg) to normalize the cardiac output and eventually vasoconstrictive agents to increase the mean arterial pressure. iii) Shortening the venous clamping time. To reduce the venous clamping time (which can be prolonged up to 45 min), an accurat e surgical strategy should be defined. For right bronchogenic tumors with carinal or proximal pulmonary artery invasion, it is often easier to perform the vascular step first and then the airway procedure. During the latter, all attention should be d irected to avoid prosthesis bacterial contamination. For mediastinal tumors involving both upper lobes, operation should be made from the left to the right side. This permits a safe and immediate revascularization between the left brachiocephalic vei n and the right atrium; the right part of the excision is performed thereafter.
 
   

7.

Which types of SVC reconstruction can be done?
Which types of SVC reconstruction can be done? When the circumference of the involved caval wall is less than 30%, a partial resection of the vein is possible. Its reconstruction can be made either directly with a running suture or indirectly with the interposition of a prosthetic or autologous pericardial or venous patch; closure up to 50% of the caval circumference can be made without hemodynamical imbalance. With larger involvements, prosthetic replacement of the SVC is necessary

Truncular replacement
It requires a tumor-free confluence of both brachiocephalic veins. This procedure, commonly associated to a right pneumonectomy, employs a straight not ringed PTFE graft (#18 or 20). After proximal (brachiocephalic veins confluence) and distal (cavoatrial junction) clampage, the invaded segment of the vein is completely excised. The proximal anastomosis between the SVC stump and the prosthesis is then performed first using a continuous 5-0 polypro pylene (Prolene, Ethicon, Inc., Somerville, NJ) suture started at the posterior aspect of the prosthesis in an in- to out-side fashion. After its completion, the distal anastomosis is then performed in the same way. Before tightening the stretches of the distal suture, the proximal clamp is released, the prosthesis is flashed with saline heparinized solution and deairation made. The distal clamp is then released and the knots tied. To avoid prosthesis kinking, the length of the graft should be adapted so that the distal anastomosis rests under tension.

Revascularization from the left brachiocephalic vein
This procedure, always performed through a median sternotomy, requires a ringed PTFE graft (#12 or 1 3). The ringed graft is imperative since after closure of the median sternotomy, the prosthesis may be too long, inducing thus its kinking. Minimal dissection of the left brachiocephalic vein is also mandatory to avoid its rotation above the proximal anastomosis. The distal anastomosis can be performed either on the right atrium or appendage or the inferior stump of the SVC.

Revascularization from the right brachiocephalic vein
Ringed grafts are preferr ed (# 12 or 14) to maintain their patency and to avoid their compression by the post-operative fibrosclerosis. The risks of kinking are minimal since the direction of the graft is almost vertical. The proximal anastomosis is not always easy to perform since the right brachiocephalic vein after its resection is often short; it has to be performed firstly. The distal anastomosis should be made on the SVC stump; this architecture results in the straightest and shortest graft. It is the revascularization of choice after resection of mediastinal tumors involving the origin of the SVC.

Revascularization of both brachiocephalic veins
Indications for revascularization of both brachiocephalic veins are extremely rare and confined only to those patients whose right or left-sided internal jugular vein is absent because of previous neck surgery (e.g. thyroid cancer surgery). In these rare situations, revascularization of a single brachiocephalic vein may result in an insufficient brain venous drainage. On the contrast, by revascularizing both brachiocephalic veins, the established venous circulation and hemodynamics is conserved. An Y-type graft should be avoided since it may result in thrombosis of the accessory limb of the Y-graft because the graft-to-graft anastomosis is thrombogenic (raw anastomotic surfaces); thus a separate distal implantation is preferable. The right graft should be anastomosed distally on the SVC stump (when possible) and the left one on the right atrium.

Apart from this indication, revascularization of both brachiocephalic veins decreases the blood flow through each graft and requires a more demanding technical procedure. For these reasons, SVC revascularization of the viable brachiocephalic vein with ligation of the contralateral brachiocephalic vein is preferred in almost all cases.
 
   

8.

Are palliative SVC by-pass(es) justified?
Thrombosis of the SVC district is usually well tolerated and sensible to medical treatment, which succeeds in limiting thrombosis extension and the development of rich collateral venous network as in inferior vena cava thrombosis. The less tolerated SVC syndromes are those associating a SVC thrombosis to an extensive thrombosis into both brachiocephalic veins and even subclavian and jugular veins. In patients harboring such SVC syndromes, SVC revascularization carries out several technical problems, like the absence of excellent proximal venous bed and presence of a well-developed collateral venous circulation. Despite revascularization of the SVC might be performed using either jugular or axillary veins, this usually results in a low venous blood flow through the graft and long prosthesis (passing subcutaneously with major kinkings and thrombosis risks); even surgical created artero-venous fistulae aiming to increase the flow through the graft are unsuccessful. We therefore do not recommend palliative SVC revascularizations, the only exception being the full patency and normal wall of one brachiocephalic vein.