Is it safe to divide and ligate the left innominate vein in complex cardiothoracic surgeries?

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is safe to divide the left innominate vein (LIV) in aortic arch surgery to improve access. Altogether, 228 relevant papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Following LIV division, the venous drainage takes place via multiple collateral systems such as the azygous/hemiazygous, the internal mammary veins, the lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus as well as the transverse sinus. The possible complications are mainly left upper limb swelling and neurological symptoms. In one case series of 14 patients, the LIV was divided and ligated to facilitate the exposure for aortic arch surgery. More than 2-year follow-up did not reveal upper limb oedema or neurological symptoms. In two cohorts of 52 patients, the LIV was ligated prior to the superior vena cava (SVC) resection for malignancy. During the mid-term follow-up, no neurological or upper limb symptoms were reported. Although in two studies with 72 and 70 patients undergoing SVC resection it was not specified how many of them had LIV ligation, no relevant complications were reported. In a report, LIV occlusion was observed in 4 patients undergoing left internal jagular vein catheterization for haemodialysis. The reported symptom was left arm swelling with no neurological problems. In a cohort of 18 patients undergoing SVC resection for malignancy and major vein reconstruction, 7 patients underwent ligation of the LIV with no neurological symptoms. It was also concluded that reconstruction of the LIV is not consistent with favourable patency. In a case series of 10 patients with central venous obstruction, collateral pathways to conduct efficient venous drainage were mapped. We conclude that division of the LIV is safe in selected patients and operations. Patients will initially have symptoms of central vein obstruction, but these will decrease with conservative management as collaterals form.

Papillary Thyroid Carcinoma: The First Case of Direct Tumor Extension into the Left Innominate Vein Managed with a Single Operative Approach

“…Postoperatively, our patient developed left arm swelling with thrombus in the left subclavian vein and was treated with anticoagulants and elastic arm compression. McPhee et al 6 demonstrated that these findings are part of the normal recovery process for left innominate vein resection and improve with conservative management as collateral vessels form. At 1-month postoperative follow-up, the patient's swelling completely resolved.…”

“…Resection of the left innominate vein was required to achieve these margins and is well tolerated. A study by Arthur et al 6 demonstrated that division and ligation of the left innominate vein is safe for patients undergoing mediastinal tumor excisions. Postoperatively, our patient developed left arm swelling with thrombus in the left subclavian vein and was treated with anticoagulants and elastic arm compression.…”

Orthotopic heart transplantation with reconstruction of persistent left superior vena cava

“…In our patient, we initially planned to ligate the PLSVC because the right SVC seemed to be larger than the PLSVC. We deemed PLSVC ligation a safe procedure because the innominate vein is sometimes simply ligated and divided to improve access (for example, in aortic arch surgery) without postoperative left upper limb swelling or neurological symptoms [8]. The method of harvesting the donor heart could not be modified in this case because the harvesting procedure preceded the recipient operation.…”

Aberrant left brachiocephalic vein is a contraindication for anterior cervicothoracic approach

“…Ligation of the left brachiocephalic vein after injury of the vein also carries possible complications, such as left upper limb swelling and neurological symptoms. 11…”