Internal jugular vein pressure monitoring guided venous reconstruction could improve perioperative safety after superior vena cava resection for mediastinal tumors: a cohort study

Abstract

Introduction: After superior vena cava (SVC) resection, the decision on unilateral or bilateral reconstruction was mostly based on the expertise of surgeons without objective measurements. This study explored the use of internal jugular vein pressure (IJVP) monitoring to guide the SVC reconstruction strategy. Methods: In a retrospective cohort, perioperative outcomes of unilateral and bilateral reconstruction based on surgeons’ experience were compared. Then, IJVP threshold was measured when temporarily clamping the left innominate vein (LIV) in a testing cohort. Venous reconstruction according to IJVP monitoring was performed in a prospective validation cohort afterwards. Perioperative outcomes were compared between the prospective and the retrospective cohorts. For some interested variables, intuitive explanations would be given using Bayesian methods. Potential risk factors for postoperative complications were investigated by multivariable analysis. Results: From March 2009 to September 2022, 57 patients underwent SVC reconstruction based on surgeons’ experience. Bayesian analysis indicated a posterior probability of 80.49% that unilateral reconstruction had less blood loss than bilateral reconstruction (median 550 mL vs. 1200 mL). Cerebral edema occurred in 2 patients after unilateral reconstruction. In the testing cohort, median IJVP was 22.7 (18-27) cmH2O after temporary LIV clamping in 10 patients. In the prospective cohort, unilateral reconstruction only was performed if the contralateral IJVP was<30 cmH2O in 16 patients. Bilateral reconstruction was performed if IJVP was≥30 cmH2O after unilateral bypass in 9 patients. No cerebral edema occurred in the prospective cohort. Less postoperative complications occurred in the prospective cohort than the retrospective cohort (12.0% vs. 38.6%, P=0.016). Upon multivariable analysis, IJVP-monitoring guided SVC reconstruction was associated with significantly less postoperative complications (P=0.033). Conclusions: Intraoperative IJVP-monitoring is a useful strategy for selection of unilateral or bilateral SVC reconstruction and improving perioperative safety in patients with mediastinal tumors.