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1.  Treatment of obstruction of the superior vena cava by combination chemotherapy with and without irradiation in small-cell carcinoma of the bronchus. 
Thorax  1983;38(7):501-505.
In a randomised prospective trial of chemotherapy with and without radiotherapy in small-cell carcinoma of the bronchus, 37 of 366 patients presented with obstruction of the superior vena cava at the time of diagnosis. In the study all patients received four cycles of combination chemotherapy over a period of 12 weeks and, provided there was not progressive disease, then received either radiotherapy to the mediastinum and primary tumour followed by eight further courses of chemotherapy or eight cycles of chemotherapy alone. Of the 37 patients presenting with superior vena caval obstruction, nine had relapsed and treatment was stopped during or after the initial four cycles of chemotherapy. Of the remainder, 15 patients received radiotherapy plus chemotherapy and 13 chemotherapy alone. After four cycles of chemotherapy (12 weeks) 21 of the 37 patients had initial complete relief of symptoms secondary to superior vena caval obstruction, 10 had substantial but partial relief, and six had no relief. Twelve patients developed recurrence of superior vena caval obstruction, of whom six had received radiotherapy and four chemotherapy alone; two relapsed in the initial 12 weeks of the study. The median survival of the patients with superior vena caval obstruction allocated at diagnosis to either treatment arm was identical. The survival of patients with obstruction was similar to that of other patients in the main study. Chemotherapy is an effective treatment for superior vena caval obstruction and there appears to be no additional advantage in giving radiotherapy after 12 weeks of cyclical chemotherapy.
PMCID: PMC459595  PMID: 6310812
2.  Flow during exercise in the total cavopulmonary connection measured by magnetic resonance velocity mapping 
Heart  2002;87(6):554-558.
Objective: To measure caval and pulmonary flows at rest and immediately after exercise in patients with total cavopulmonary connection (TCPC).
Design: An observational study using the patients as their own controls.
Setting: Using a combination of magnetic resonance (MR) phase contrast techniques and an MR compatible bicycle ergometer, blood flow was measured in the superior vena cava, the tunnel from the inferior vena cava, and in the left and right pulmonary arteries during rest and on exercise (0.5 W/kg and 1.0 W/kg).
Patients: Eleven patients aged 11.4 (4.6) years (mean (SD)) were studied 6.3 (3.8) years after TCPC operation.
Main outcome measures: Volume flow measured in all four branches of the TCPC connection during rest and exercise.
Results: Systemic venous return (inferior vena cava plus superior vena cava) increased from 2.5 (0.1) l/min/m2 (mean (SEM)) to 4.4 (0.4) l/min/m2 (p < 0.05) during exercise, with even distribution to the two pulmonary arteries. At rest, inferior vena caval flow was higher than superior vena caval flow, at 1.4 (0.1) v 1.1 (0.1) l/min/m2 (p < 0.05). During exercise, inferior vena caval flow doubled (to 3.0 (0.3) l/min/m2) while superior vena caval flow only increased slightly (to 1.4 (0.1) l/min/m2) (p < 0.05). The increased blood flow mainly reflected an increase in heart rate. The inferior vena caval to superior vena caval flow ratio was 1.4 (0.1) at rest and increased to 1.8 (0.1) (p < 0.05) at 0.5 W/kg, and to 2.2 (0.2) at 1.0 W/kg (p < 0.05).
Conclusions: Quantitative flow measurements can be performed immediately after exercise using MR techniques. Supine leg exercise resulted in a more than twofold increase in inferior vena caval flow. This was equally distributed to the two lungs, indicating that pulmonary resistance rather than geometry decides flow distribution in the TCPC circulation.
PMCID: PMC1767137  PMID: 12010939
flow; Fontan circulation; exercise; magnetic resonance imaging
3.  What we learned from difficult hepatectomies in patients with advanced hepatic malignancy 
By reviewing difficult resections for advanced hepatic malignancies, we discuss the effectiveness and extended indications for hepatectomy in such patients.
We reviewed 7 patients who underwent extensive surgery between July 2008 and March 2011 for advanced hepatic malignancies. They had stage IV disease, except for in one case that was a stage IIIC (T4N0M0) hepatocellular carcinoma (HCC).
Patient 1 with intrahepatic cholangiocarcinoma (IHCC) underwent right hemihepatectomy and resection of the bile duct and left portal vein. At 39 months after surgery, she had no recurrence or metastasis. Patient 2 with HCC underwent palliative right trisectionectomy. At 38 months after surgery, he is alive despite residual pulmonary metastases. Patient 3 with HCC invading the hepatic vein and diaphragm underwent right trisectionectomy and caval venoplasty. At 12 months after surgery, he had no recurrence or metastasis. Patient 4, who had 2 large HCCs and pulmonary thromboembolism, underwent a right trisectionectomy. At 7 months after surgery, he had no evidence of recurred HCC. Patient 5, who had IHCC invading her inferior vena cava and main portal vein, underwent preoperative radiotherapy, left hemihepatectomy, and caval resection. At 20 months after surgery, she is well despite a caval thrombus. Patient 6 and 7 underwent repeated surgery due to a recurred IHCC and metastatic colon cancer, respectively. In addition, they are alive during each 20 and 17 months after surgery.
Despite macroscopic extrahepatic metastases or major vessel involvement, extensive surgery for advanced hepatic malignancy may result in relatively favorable outcomes and be important modality for improving of survival in such patients.
PMCID: PMC4582463  PMID: 26421042
Hepatocellular carcinoma; Intrahepatic cholangiocarcinoma; Hepatectomy
4.  Surgical repair of tricuspid atresia 
Thorax  1971;26(3):240-248.
Surgical repair of tricuspid atresia has been carried out in three patients; two of these operations have been successful. A new surgical procedure has been used which transmits the whole vena caval blood to the lungs, while only oxygenated blood returns to the left heart. The right atrium is, in this way, `ventriclized', to direct the inferior vena caval blood to the left lung, the right pulmonary artery receiving the superior vena caval blood through a cava-pulmonary anastomosis. This technique depends on the size of the pulmonary arteries, which must be large enough and at sufficiently low pressure to allow a cava-pulmonary anastomosis. The indications for this procedure apply only to children sufficiently well developed. Younger children or those whose pulmonary arteries are too small should be treated by palliative surgical procedures.
PMCID: PMC1019078  PMID: 5089489
5.  Intimal sarcoma of the superior vena cava. 
Postgraduate Medical Journal  1993;69(808):155-156.
A case of superior vena cava syndrome caused by a primary intimal sarcoma of the superior vena cava is described. The known causes of superior vena caval obstruction are discussed, together with the difficulties in identifying the underlying lesion. The possibility of a primary superior vena caval neoplasm as a cause of superior vena caval obstruction should be considered in patients presenting with superior vena caval syndrome.
PMCID: PMC2399625  PMID: 8506202
6.  Stereotactic body radiotherapy for superior vena cava syndrome 
Superior vena cava syndrome (SVCS) is characterized by a spectrum of clinical findings that result from the occlusion of the superior vena cava (SVC), usually caused by extracaval compression of the SVC by either a bronchogenic tumor or an enlarged mediastinal lymph node. Most efforts at treatment for SVCS are palliative, and long-term survival for malignancy-related SVCS is very low. Therefore, radiotherapy treatment is usually delivered with palliative intent utilizing hypofractionated regimens. The use of high dose per fraction may result in more rapid and more durable responses to treatment. Similarly, the high dose per fraction utilized in stereotactic body radiotherapy (SBRT) has been proven highly efficacious in treating early stage non-small cell lung cancer (NSCLC). Here we report the first reported case of a patient with SVCS from NSCLC successfully treated with SBRT to alleviate SVCS.
PMCID: PMC3863254  PMID: 24416550
Stereotactic; Superior vena cava syndrome; SBRT; SVCS
7.  Expandable Wallstent for the treatment of obstruction of the superior vena cava. 
Thorax  1993;48(9):915-920.
BACKGROUND--Palliative treatments for obstruction of the superior vena cava all have disadvantages. The use of a fine braided wire self expanding stent (Wallstent, Schneider (Europe) AG) in patients with malignant and benign causes of superior vena cava obstruction is reported. METHODS--Five patients with obstruction of the superior vena cava were treated with balloon angioplasty of the stricture and the percutaneous insertion of an expandable Wallstent endoprosthesis across the site of the stricture. Four patients had advanced mediastinal malignancy previously treated by radiotherapy and one patient had fibrosing mediastinitis. RESULTS--All patients experienced rapid symptomatic relief and, in three cases, complete palliation was achieved during survival times of seven weeks, nine weeks, and 24 weeks, respectively. Two surviving patients (with a recurrent thymoma and fibrosing mediastinitis) were free of symptoms when followed up at eight and nine months respectively. CONCLUSIONS--Initial experience with the Wallstent endoprosthesis suggests that it is a valuable treatment alternative once conventional therapy has failed and gives rapid relief of symptoms to patients with obstruction of the superior vena cava.
PMCID: PMC464777  PMID: 7694384
8.  Subclavian thrombosis in a patient with advanced lung cancer: a case report 
Lung cancer is now considered the most common cause of death among cancer patients. Although target biological regimens have emerged in recent years for non-small cell lung carcinoma, the survival and quality of life of patients with this condition still remain low. The five-year survival rate for all stages of lung cancer is 17% or less.
Case presentation
We describe the case of a 53-year-old Caucasian woman who was diagnosed with advanced stage IIIa (T2aN2M0) non-small cell lung carcinoma (adenocarcinoma) and underwent a complete left upper lobectomy three years ago. After two and a half years of follow-up, she suddenly presented with facial edema and venous distension and was immediately treated for superior vena cava syndrome. Because of a diagnostic check, a major clot was detected in the right subclavian vein. Our patient was informed about treatment options, and she was taken to the catheterization laboratory for percutaneous stenting of the superior vena cava to restore superior vena cava patency.
Lung cancer has a vast number of complications. Superior vena cava syndrome and thrombosis should be considered upon the presentation of a patient with obstructive symptoms. In this case report, even though we expected the clot to be on the side of the former lesion, it was present on the opposite side. Treatment should also start immediately in these patients with clinical suspicion of thrombosis to avoid further complications, even in cases with a differential diagnosis problem. Finally, although patients with non-small cell lung carcinoma have a high incidence of thromboembolic events, anticoagulant treatment is given only as maintenance therapy after a first event occurs.
PMCID: PMC3110134  PMID: 21548918
9.  Blood Flow Distribution in a Large Series of Fontan Patients: A Cardiac Magnetic Resonance Velocity Mapping Study 
To determine flow distribution in the cavopulmonary connections of Fontan patients with and without bilateral superior vena cavae. No large series exists that establishes the flow distributions in Fontan patients, which would be an important resource for everyday clinical use and may impact future surgical reconstruction.
We studied 105 Fontan patients (ages 2 - 24 years) with through-plane phase contrast velocity mapping to determine flow rates in the inferior and superior vena cava, and left and right pulmonary arteries. Superior caval anastomosis type included 40 bidirectional Glenns (of which 15 were bilateral) and 53 hemi-Fontans, while Fontan type included 69 intra-atrial baffles, 28 extracardiac conduits, and 4 atriopulmonary connections.
Total caval flow was 2.9±1.0 l/min/m2, with an inferior vena cava contribution of 59%±15%. Total pulmonary flow was 2.5±0.8 l/min/m2, statistically less than caval flow and not explained by fenestration presence. The right pulmonary artery contribution (55%±13%) was, statistically greater than the left. In patients with bilateral superior cavae, the right cava accounted for 52%±14% of the flow, with no difference in pulmonary flow splits (50%±16% to the right). Age and body surface area correlated with percent inferior caval contribution (r = 0.60 and 0.74 respectively). Superior vena cava anastomosis and Fontan type did not significantly affect pulmonary flow splits.
Total Fontan cardiac index was 2.9 l/min/m2, with normal pulmonary flow splits (55% to right lung). Inferior vena cava contribution to total flow increases with body surface area and age, consistent with data from healthy children.
PMCID: PMC2752985  PMID: 19577063
cardiac magnetic resonance imaging; Fontan procedure; total cavopulmonary connection; single ventricle physiology; blood flow; congenital heart disease; pediatric cardiology
10.  Superior vena cava syndrome secondary to thyroid cancer 
It is uncommon for thyroid cancer to present with superior vena cava syndrome. Obstruction of superior vena cava can develop as a result of intrinsic and extrinsic spread of the thyroid cancer. The usual presentation of this disease entity is a neck mass with symptoms and signs suggestive of superior vena cava obstruction. Superior vena cava obstruction is commonly caused by lung cancer and lymphoma. However, thyroid cancer can cause superior vena cava obstruction by downward tumour spread into the mediastinum causing extrinsic compression, which will lead to narrowing and thrombosis of the major venous system in the chest. Paraganglioma can also present with superior vena cava obstruction and it mimics thyroid cancer microscopically. Proper staining should be performed to differentiate between the two diseases. This could be the first case of this kind reported in the literature.
PMCID: PMC3649273  PMID: 24950045
11.  AB 58. The current role of 3-D conformal radiotherapy in syndrome of vena superior. The experience in University General Hospital of Thessaloniki, AHEPA 
Journal of Thoracic Disease  2012;4(Suppl 1):AB58.
The syndrome of Vena Cava Superior (SVCS) usually is caused from tumor-mass of lung cancer, which blockage the vena cava superior. It appears with swelling in face, redness, and dyspnoea. It is an urgent condition in medical clinical Oncology and demands urgently external beam radiotherapy. The immediately current role of 3D conformal external radiotherapy in Syndrome of Vena Cava Superior.
Patients and methods
A total of 16 patients with lung cancer and Syndrome of Vena Cava superior came in Department of Radiation therapy in U.G.H.TH.AHEPA, in the period 2010-2012. 6 patients revealed acute symptoms (swelling, dyspnoea). A total of 10 patients revealed incipient Syndrome of vena cava superior. Computered Tomography of Thorax showed tumor mass which caused blockage in the vena cava superior, in all of the patients. It has been made biopsy and it was excluded the diagnosis of Lymphoma or tumor of genital cells. All of the patients were submitted immediately in CT-Simulator equation, 2D-3D Conformal Treatment Planning with linear accelerator with MLC-multilief Collimator (blocks for protection the organs at risk (OAR)-heart, spinal cord, unilateral lung. Patients with incipient Syndrome received 10 fractions with 300 cGy/fraction in two weeks (3.000 cGy). Patients with already installed Syndrome V.C.S. (with acute symptoms) received in the first two fractions 400 cGy/fraction and they continued with 6 fractions with 300 cGy/fraction. Total dose was 2.600 cGy.
Patients were rehabilitated their respiratory function after the second fraction. Swelling and redness in the face did not appear after third fraction. A total of 14 patients after the end of radiotherapy were in excellent performance status. In 2 patients the minimal dyspnoea disappeared two weeks after the end of radiotherapy. One month after the end of radiotherapy the CT of thorax showed reduce of the tumor mass. Respiratory function was in complete rehabilitation.
The immediately urgently external beam radiotherapy, in a few days and high dose, compose an excellent therapeutical approach for the patients with Syndrome of Vena Cava Superior. Relieves from the symptoms in patients, increasing their overall survive and give improvement in the quality of life.
PMCID: PMC3537351
12.  Proximal tubular function in dogs with thoracic caval constriction 
Journal of Clinical Investigation  1971;50(10):2150-2158.
The effect of saline infusion on proximal sodium reabsorption was compared in normal dogs and in dogs with acute or chronic partial thoracic vena cava obstruction. After acute vena cava obstruction, proximal fractional sodium reabsorption rose by 74%. During continued caval obstruction, saline loading strikingly reduced proximal reabsorption but sodium excretion remained minimal. In chronic caval dogs, saline loading reduced proximal fractional sodium reabsorption by 31% but sodium excretion in the micropunctured kidney was only 41 μEq/min. After saline infusion in normal dogs, proximal fractional sodium reabsorption fell 39% while unilateral sodium excretion rose to 584 μEq/min.
Nephron filtration rate was also measured before and after saline loading in normal and chronic caval dogs in both repunctured and fresh tubules. There was a marked increase in nephron filtration rate in repunctured tubules and no change in freshly punctured tubules in both groups. The effect of saline loading on nephron filtration rate in normal and chronic caval dogs was similar, therefore, whether repunctured or fresh nephrons were considered.
We conclude that saline infusion depresses proximal sodium reabsorption in acute and chronic TVC dogs. Since saline loading markedly increases distal delivery without a concomitant natriuresis, enhanced distal reabsorption must play a major role in the sodium retention exhibited by chronic caval dogs. Redistribution of filtrate does not appear to be a factor in this sodium retention.
PMCID: PMC292149  PMID: 5116206
13.  Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists 
Oncology Letters  2015;10(5):3043-3049.
Oncologists commonly overestimate the survival time of patients receiving palliative therapy, which may result in the administration of treatments that are too aggressive for patients near the end of their lives. Previous studies have discussed the negative implications of palliative radiotherapy if administered during the last month of life. Models predicting a limited survival time may improve the ability of the oncologists to tailor the treatment according to the needs of each individual patient. In the present study, prognostic factors for survival time, and the use of palliative radiotherapy during the last month of life, were analyzed in 873 patients. Models predicting the likelihood of administering such therapy were examined, and the risk of receiving radiotherapy during the last month of life was observed to be lower in patients with non-metastatic cancer than in those with metastatic cancer (7 vs. 13%, respectively; P=0.12). On multivariate analysis, 11 factors that significantly influenced the survival time were identified. These findings emphasize the complexity of potential prediction models. The most important risk factor regarding the prediction of extremely short survival times was observed to be an Eastern Cooperative Oncology Group performance status (ECOG PS) of 4, followed by an ECOG PS of 3 (median survival times, 14 and 64 days, respectively). A limited number of patients who received palliative radiotherapy during their last month of life died unexpectedly. Disease-specific prediction models were developed; however, the small number of events available for analysis limited their immediate clinical impact. Furthermore, these prediction models identified a minority of patients who received radiotherapy during the last month of life. In conclusion, the majority of the palliative radiotherapy courses administered to patients with advanced cancer during their last month of life may be preventable if accurate decision models for the clinic are developed. However, due to the complexity associated with the prediction of survival times in patients receiving palliative radiotherapy, large databases are required to allow accurate models to be established. The present study also discusses the recommendations of the Department of Oncology and Palliative Medicine of Nordland Hospital (Bodø, Nordland, Norway) with regard to the use of palliative radiotherapy during the last month of life of patients with terminal cancer.
PMCID: PMC4665322  PMID: 26722287
radiation oncology; palliative radiotherapy; prognostic factors; prognostic score; decision making
14.  Radical nephrectomy with vena caval thrombectomy: a contemporary experience 
BJU international  2010;107(9):1386-1393.
To report on the contemporary Memorial Sloan-Kettering Cancer Center experience with radical nephrectomy and vena caval thrombectomy.
Patients who underwent radical nephrectomy and vena caval thrombectomy without the use of bypass techniques were retrospectively identified.
Data were collected on intraoperative and pathological findings as well as postoperative complications and oncological outcomes.
In all, 78 patients underwent radical nephrectomy with off-bypass resection of vena caval thrombus between 1989 and 2009.
The median (interquartile range, IQR) operation duration was 293 (226–370) min, and median (IQR) blood loss was 1300 (750–2500) mL. In all, 10 patients (13%) were confirmed to have intra- or supra-hepatic tumour thrombus (level 3/4), eight of whom required supra-hepatic control of the inferior vena cava (IVC).
Major (grade 3–5) postoperative complications occurred in 14 (18%), with five postoperative deaths. Disease recurred in 27/62 patients who were considered completely resected at surgery and had adequate follow-up.
The overall 5-year survival (95% confidence interval) probability was 48% (35–60%).
Radical nephrectomy with vena caval thrombectomy is associated with acceptable postoperative morbidity and mortality, and long-term survival is possible in some patients.
Many level 3/4 thrombi could be safely approached without the use of bypass techniques.
PMCID: PMC4315148  PMID: 20883481
RCC; kidney; vena cava; nephrectomy
15.  Jugular venous `a' wave in pulmonary hypertension: new insights from a Doppler echocardiographic study 
British Heart Journal  1992;68(2):187-191.
Objective—To study the mechanisms underlying the dominant `a' wave seen in patients with primary pulmonary hypertension.
Design—Retrospective and prospective examination of the jugular venous pulse recording, flow in the superior vena cava, and Doppler echocardiographic studies.
Setting—A tertiary referral centre for both cardiac and pulmonary disease, with facilities for invasive and noninvasive investigation, and assessment for heart and heart-lung transplantation.
Patients—12 patients with primary pulmonary hypertension, most being considered for heart-lung transplantation.
Results—Two distinct patterns of venous pulse and superior vena caval flow were identified: a dominant `a' wave with no `v' wave, an absent or poorly developed `y' descent, and exclusively systolic downward flow in the superior vena cava (group 1, n = 8), and a dominant `v' wave, deep `y' descent and exclusively diastolic downward flow in the superior vena cava (group 2, n = 4). A comparison between the two groups showed age (mean (SD)) 42 (18) ν 36 (7) years, RR interval 700 (65) ν 740 (240) ms, left ventricular end diastolic dimension 3·6 (0·8) ν 3·2 (1·0) cm and end systolic dimension 2·1 (0·5) ν 2·3 (0·3) cm, right ventricular end diastolic dimension 2·6 (0·5) ν 2·8 (0·6) cm, and pressure drop between right ventricle and right atrium 60 (8) ν 70 (34) mm Hg to be similar. Duration of tricuspid regurgitation 520 (30) ν 420 (130) ms and the time interval of pulmonary closure to the end of the tricuspid regurgitant signal 140 (30) ν 110 (40) ms were longer in group 1 compared with group 2, whereas right ventricular filling time was much shorter 180 (70) ν 350 (130) ms. In seven patients from group 1, a single peak of forward tricuspid flow was present, but this pattern was seen in only one patient from group 2.
Conclusions—In patients with primary pulmonary hypertension, the apparent `a' wave seen in the venous pulse is, in fact, a summation wave. It is probably the result of large pressure changes that must underlie rapid acceleration and deceleration of blood across the tricuspid valve when the right ventricular filling time is short.
PMCID: PMC1025012  PMID: 1389735
16.  Radiotherapy for oncologic emergencies on weekends: examining reasons for treatment and patterns of practice at a Canadian cancer centre 
Current Oncology  2009;16(4):55-60.
Radiotherapy for oncologic emergencies is an important aspect of the management of cancer patients. These emergencies—which include malignant spinal cord compression, brain metastases, superior vena cava obstruction, and uncontrolled tumour hemorrhage —may require treatment outside of hospital hours, particularly on weekends and hospital holidays. To date, there remains no consensus among radiation oncologists regarding the indications and appropriateness of radiotherapy treatment on weekends, and treatment decisions remain largely subjective. The main aim of the present study was to document the incidence and indications for patients receiving emergency treatment on weekends or scheduled hospital holidays at a single institution. The secondary aim was to investigate the compliance of such treatment with the institution’s quality assurance policies, both local and provincial.
From September 1, 2002, to September 30, 2004, patients being treated over weekends (defined as commencing at 6 pm on a Friday and concluding at 8 am of the next scheduled workday) and hospital holidays were retrospectively identified using the Oncology Patient Information System scheduling module. Relevant patient data—including patient age, sex, primary cancer site, specific radiation field, rationale for treatment, referring hospital, total treatment dose, radiation dose fractionation, inpatient or outpatient status, and duration of treatment—were collected and subsequently analyzed. Comparison to local policy was performed subjectively.
Over the 2-year period, 161 patients were prescribed urgent radiotherapy over a weekend or on a hospital holiday. Of this cohort, 68% were treated on both Saturday and Sunday, 22% on Saturday alone, and 10% on Sunday alone. Most patients presented with lung (31%), prostate (18%), and breast cancer (17%). The top reasons for referral for emergency weekend treatment included spinal cord compression (56%), brain metastases (15%), and superior vena cava obstruction (6%). Most of the indications for treatment generally followed the quality assurance policies implemented both locally and provincially.
Patients treated over a weekend or on a hospital holiday were generally found to be treated with appropriate intent. Most treatment indications within this study both complied with provincial policy and showed a pattern of care similar to that seen in other studies in the literature. Local policy appears to be robust; however, policy improvements may allow for more cohesiveness across radiation oncologists in patterns of care in this important group of patients. Comparisons with practice at other institutions would be valuable and also a key step in developing sound guidelines for all members of the radiotherapy community to follow.
PMCID: PMC2722059  PMID: 19672425
Emergency radiation treatment; metastases; spinal cord compression; weekend radiation treatment
17.  Treatment of malignant obstruction of the superior vena cava with the self-expanding Wallstent. 
Thorax  1995;50(11):1151-1156.
BACKGROUND--Obstruction of the superior vena cava (SVC) in malignant disease can cause considerable distress to patients. Symptomatic relief can be achieved by the percutaneous implantation of a self-expanding stent (Wallstent) into the stenosis. METHODS--Fourteen patients with obstruction of the SVC were treated with one to three Wallstent endoprostheses. They suffered from advanced bronchogenic carcinoma (n = 12), thyroid carcinoma (n = 1), and breast carcinoma (n = 1). The indication for stent placement was symptomatic obstruction of the SVC and incurable disease. Stenting was performed for symptom relief, and before, during, and after courses of radiotherapy or chemotherapy as needed. RESULTS--Twelve patients experienced complete symptomatic relief within two days of stent placement. Two patients did not benefit. Three patients not given anticoagulation developed stent thrombosis between one week and eight months after initial placement, and within one day of endobronchial stent implantation with bronchial laser therapy or balloon dilatation in all three. Patency of the SVC was achieved again by a repeat procedure. CONCLUSIONS--Stent placement for obstruction of the SVC gives rapid symptomatic relief. Subsequent endobronchial stent implantation with bronchial laser therapy or balloon dilatation could be a risk for caval stent occlusion. Stent thrombosis remains a problem in patients who are not anticoagulated.
PMCID: PMC475086  PMID: 8553270
18.  Surgical management of tricuspid atresia 
Thorax  1969;24(2):239-245.
Tricuspid atresia is one of the less common forms of congenital heart disease. The results of palliative surgery in 72 children are presented. Cardiac catheterization and angiocardiography are essential for precise definition of the anomaly. There is a 20% incidence of obstruction at atrial septal level. Closed atrial septostomy is of value in such cases in infancy. In most there is a reduced pulmonary blood flow. This may be increased by anastomosis of either the superior vena cava or a systemic artery to the pulmonary artery. The caval anastomosis, while having theoretical advantages, is not always possible, especially in small infants. In this series systemic arterial shunts have given at least comparable results, suggesting that both techniques are of value with this anomaly.
PMCID: PMC471945  PMID: 5821626
19.  Transcaval repair of sinus venosus defect. Using a butterfly-shaped patch. 
Texas Heart Institute Journal  1995;22(4):304-307.
We describe an operative technique used in 30 patients from 1982 to 1995, in which sinus venosus atrial septal defect with anomalous pulmonary venous connection is repaired through longitudinal incision confined to the vena cava. A single oval patch is folded like the wings of a butterfly: the posterior wing is used to separate superior vena caval and pulmonary venous blood, and the anterior wing is used to enlarge the terminal cava. This approach avoids both sinus node dysfunction and superior vena caval or pulmonary venous obstruction. Operative findings suggest that the sinus venosus defect is a malformation involving abnormal confluence of sinus venosus, anomalous right superior pulmonary, and right common cardinal veins. Further, the sinus venosus contributes more to the formation of the right atrium, displacing the crista terminalis downward and forward and separating the atrial component of the right atrium from the terminal cava.
PMCID: PMC325278  PMID: 8605430
20.  Immediate versus delayed palliative thoracic radiotherapy in patients with unresectable locally advanced non-small cell lung cancer and minimal thoracic symptoms: randomised controlled trial 
BMJ : British Medical Journal  2002;325(7362):465.
To determine whether patients with locally advanced non-small cell lung cancer unsuitable for resection or radical radiotherapy, and with minimal thoracic symptoms, should be given palliative thoracic radiotherapy immediately or as needed to treat symptoms.
Multicentre randomised controlled trial.
23 centres in the United Kingdom, Ireland, and South Africa.
230 patients with previously untreated, non-small cell lung cancer that is locally too advanced for resection or radical radiotherapy with curative intent, with minimal thoracic symptoms, and with no indication for immediate thoracic radiotherapy.
All patients were given supportive treatment and were randomised to receive palliative thoracic radiotherapy either immediately or delayed until needed to treat symptoms. The recommended regimens were 17 Gy in two fractions one week apart or 10 Gy as a single dose.
Main outcome measures
Primary—patients alive and without moderate or severe cough, chest pain, haemoptysis, or dyspnoea six months from randomisation, as recorded by clinicians. Secondary—quality of life, adverse events, survival.
From December 1992 to May 1999, 230 patients were randomised. 104/115 of the patients in the immediate treatment group received thoracic radiotherapy (90 received one of the recommended regimens). In the delayed treatment group, 48/115 (42%) patients received thoracic radiotherapy (29 received one of the recommended regimens); 64 (56%) died without receiving thoracic radiotherapy; the remaining three (3%) were alive at the end of the study without having received the treatment. For patients who received thoracic radiotherapy, the median time to start was 15 days in the immediate treatment group and 125 days in the delayed treatment group. The primary outcome measure was achieved in 28% of the immediate treatment group and 26% of patients from the delayed treatment group (27/97 and 27/103, respectively; absolute difference 1.6%, 95% confidence interval –10.7% to 13.9%). No evidence of a difference was observed between the two treatment groups in terms of activity level, anxiety, depression, and psychological distress, as recorded by the patients. Adverse events were more common in the immediate treatment group. Neither group had a survival advantage (hazard ratio 0.95, 0.73 to 1.24; P=0.71). Median survival was 8.3 months and 7.9 months, and the survival rates were 31% and 29% at 12 months, for the immediate and delayed treatment groups, respectively.
In minimally symptomatic patients with locally advanced non-small cell lung cancer, no persuasive evidence was found to indicate that giving immediate palliative thoracic radiotherapy improves symptom control, quality of life, or survival when compared with delaying until symptoms require treatment.
What is already known on this topicRadiotherapy is commonly given to patients with inoperable non-small cell lung cancer in the United KingdomOne or two fractions of palliative radiotherapy can control thoracic symptomsWhat this study addsIn the group of patients with no symptoms or only minimal symptoms, palliative thoracic radiotherapy can be safely deferred until significant thoracic symptoms appearCompared with immediate, palliative radiotherapy, no evidence exists that such a policy affects patients' survival or levels of activity, anxiety, or depression
PMCID: PMC119441  PMID: 12202326
21.  Fetal circulation in left-sided congenital heart disease measured by cardiovascular magnetic resonance: a case–control study 
The distribution of blood flow in fetuses with congenital heart disease (CHD) is likely to influence fetal growth, organ development, and postnatal outcome, but has previously been difficult to study. We present the first measurements of the distribution of the fetal circulation in left-sided CHD made using phase contrast cardiac magnetic resonance (CMR).
Twenty-two fetuses with suspected left-sided CHD and twelve normal controls underwent fetal CMR and echocardiography at a mean of 35 weeks gestation (range 30–39 weeks).
Fetuses with left-sided CHD had a mean combined ventricular output 19% lower than normal controls (p < 0.01). In fetuses with left-sided CHD with pulmonary venous obstruction, pulmonary blood flow was significantly lower than in those with left-sided CHD without pulmonary venous obstruction (p < 0.01). All three fetuses with pulmonary venous obstruction had pulmonary lymphangectasia by fetal CMR and postnatal histology. Fetuses with small but apex forming left ventricles with left ventricular outflow tract or aortic arch obstruction had reduced ascending aortic and foramen ovale flow compared with normals (p < 0.01). Fetuses with left-sided CHD had more variable superior vena caval flows than normal controls (p < 0.05). Six fetuses with CHD had brain weights at or below the 5th centile for gestational age, while none of the fetuses in the normal control group had brain weights below the 25th centile.
Measurement of the distribution of the fetal circulation in late gestation left-sided CHD is feasible with CMR. We demonstrated links between fetal blood flow distribution and postnatal course, and examined the relationship between fetal hemodynamics and lung and brain development. CMR enhances our understanding of pathophysiology of the fetal circulation and, with more experience, may help with the planning of perinatal management and fetal counselling.
PMCID: PMC3735489  PMID: 23890187
22.  Palliative radiotherapy in patients with a poor performance status: the palliative effect is correlated with prolongation of the survival time 
The purpose of this study was to analyze the efficacy and tolerability of palliative radiotherapy (RT) in patients with a poor performance status (PS) and to evaluate the relationship between the palliative effect and survival time.
One hundred and thirty-three patients with a poor PS (Eastern Cooperative Oncology Group 3 or 4) were treated with palliative RT using the three-dimensional conformal technique and retrospectively analyzed. Each patient's primary symptom treated with palliative RT as the major cause of the poor PS was evaluated using the second item of the Support Team Assessment Schedule (STAS) at the start and one week after the completion of palliative RT.
One hundred and fourteen (86%) of the 133 patients completed the planned palliative radiation dose. Grade 3 acute toxicity was observed in two patients (2%) and Grade 2 acute toxicity was observed in 10 patients (9%). No Grade 2 or higher late toxicities were observed, except for Grade 3 radiation pneumonitis in one patient. Improvement in the STAS scores between pre- and post-palliative RT was recorded in 76 (61%) of the 125 patients with available scores of STAS. A significant improvement in the mean STAS score between pre- and post-palliative RT was recognized (p < 0.0001). Improvement in the STAS score was found to be the most statistically significant prognostic factor for overall survival after palliative RT in both the multivariate and univariate analyses. The median overall survival time in the patients with an improvement in the STAS score was 6.4 months, while that in the patients without improvement was 2.4 months (p < 0.0005).
Palliative RT in patients with a poor PS provides symptomatic benefits in more than half of patients without inducing severe toxicities. The palliative effect is strongly correlated with prolongation of the survival time and may contribute to improving the remaining survival time in patients with metastatic/advanced cancer with a poor PS.
PMCID: PMC3707862  PMID: 23829540
Palliative radiotherapy; Symptomatic relief; Support team assessment schedule
23.  Lung cancer physicians’ referral practices for palliative care consultation 
Annals of Oncology  2011;23(2):382-387.
Integration of palliative care with standard oncologic care improves quality of life and survival of lung cancer patients. We surveyed physicians to identify factors influencing their decisions for referral to palliative care.
We provided a self-administered questionnaire to physicians caring for lung cancer patients at five medical centers. The questionnaire asked about practices and views with respect to palliative care referral. We used multiple regression analysis to identify predictors of low referral rates (<25%).
Of 155 physicians who returned survey responses, 75 (48%) reported referring <25% of patients for palliative care consultation. Multivariate analysis, controlling for provider characteristics, found that low referral rates were associated with physicians’ concerns that palliative care referral would alarm patients and families [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.21–0.98], while the belief that palliative care specialists have more time to discuss complex issues (OR 3.07, 95% CI 1.56–6.02) was associated with higher rates of referral.
Although palliative care consultation is increasingly available and recommended throughout the trajectory of lung cancer, our data indicate it is underutilized. Understanding factors influencing decisions to refer can be used to improve integration of palliative care as part of lung cancer management.
PMCID: PMC3265546  PMID: 21804051
lung cancer; palliative care; physician; survey
24.  Caval-Aortic Access to Allow Transcatheter Aortic Valve Replacement in Patients Otherwise Ineligible: Initial Human Experience 
We describe the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava.
TAVR is attractive in high risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which risk major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals.
We performed a single center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients undergoing TAVR via caval-aortic access.
Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access. 79% were women. Caval-aortic access and tract closure was successful in all 19; TAVR was successful in 17. Six patients suffered modified VARC-2 major vascular complications, two (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Through 111 (39–229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post procedure. Of 16 who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract.
Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.
PMCID: PMC4105161  PMID: 24814495
Caval-aortic; transcaval; transcatheter aortic valve replacement; extra-anatomic procedures
25.  Palliative care provision for patients with chronic obstructive pulmonary disease 
Chronic obstructive pulmonary disease (COPD) is a major cause of disability, morbidity and mortality in old age. Patients with advanced stage COPD are most likely to be admitted three to four times per year with acute exacerbations of COPD (AECOPD) which are costly to manage. The adverse events of AECOPD are associated with poor quality of life, severe physical disability, loneliness, and depression and anxiety symptoms. Currently there is a lack of palliative care provision for patients with advanced stage COPD compared with cancer patients despite having poor prognosis, intolerable dyspnoea, lower levels of self efficacy, greater disability, poor quality of life and higher levels of anxiety and depression. These symptoms affect patients' quality of life and can be a source of concern for family and carers as most patients are likely to be housebound and may be in need of continuous support and care. Evidence of palliative care provision for cancer patients indicate that it improves quality of life and reduces health care costs. The reasons why COPD patients do not receive palliative care are complex. This partly may relate to prognostic accuracy of patients' survival which poses a challenge for healthcare professionals, including general practitioners for patients with advanced stage COPD, as they are less likely to engage in end-of-life care planning in contrast with terminal disease like cancer. Furthermore there is a lack of resources which constraints for the wider availability of the palliative care programmes in the health care system. Potential barriers may include unwillingness of patients to discuss advance care planning and end-of-life care with their general practitioners, lack of time, increased workload, and fear of uncertainty of the information to provide about the prognosis of the disease and also lack of appropriate tools to guide general practitioners when to refer patients for palliative care. COPD is a chronic incurable disease; those in an advanced stage of the disease pursuing intensive medical treatment may also benefit from the simultaneous holistic care approach of palliative care services, medical services and social services to improve quality of end of life care.
PMCID: PMC1852092  PMID: 17407591

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