Many techniques have been described for SVC reconstruction including the use of spiral saphenous vein, autologous and bovine pericardium, and vascular prostheses, such as externally stented polytetraflouroethylene grafts. Due to wall compliance consistent with vascular tissue, superior handling characteristics, and low thrombogenicity, human cryopreserved arterial allografts have recently been utilized for SVC reconstruction following resection for malignancy [1–3]. We report a patient with symptomatic SVC obstruction secondary to mediastinal fibrosis successfully treated with resection and reconstruction using a thoracic aortic allograft.

SVC reconstruction remains a surgical challenge and the optimal method is unknown. All currently utilized methods have limitations, the most significant of which is an inherent risk of thrombosis in a low pressure/flow venous system. We believe there are several advantages of utilizing an allograft for SVC reconstruction. Although controversial, the cryopreservation process of aortic allografts has been shown to potentially diminish endothelial antigenicity with a flow surface more resistant to inflammatory responses and secondary clot formation when used in the arterial system [1–3]. Long-term studies with respect to ABO/HLA matched and unmatched vascular allografts are however needed in this regard. Aortic allografts confer a wall compliance more closely related native vascular tissue. Tissue handling and suturing is superior as compared to other conduits. Finally, aside from thawing, no preparation is necessary. Although the natural curvature of an ascending aorta allograft has been used as a “bypass” conduit from the left innominate vein to the right atrial appendage, we believe that orthotopic SVC reconstruction or direct right innominate vein to SVC reconstruction represents an optimal approach for patients who require resection of the innominate vein confluence. SVC conduits routed orthotopically or right innominate to SVC conduits would likely be more physiologic and less subject to kinking from lung or cardiac motion [4, 5].

We believe this is the first report of an aortic allograft used for SVC reconstruction due to symptomatic obstruction secondary to fibrosing mediastinitis. In light of the benign etiology, the additional expense of an allograft as compared to standard prosthetic vascular grafts can more easily be justified. In this regard, either a descending thoracic or abdominal aorta allograft, if available, may represent a somewhat less expensive option. Based on early experience, further study with allograft tissue for SVC/innominate vein reconstruction is warranted for both benign and malignant conditions.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.