Role of Transesophageal Echocardiography in the Surgical Treatment of Malignant Thrombosis of the Superior Vena Cava

This is a case of malignant superior vena cava thrombosis successfully treated during open surgical treatment. A 70-year-old woman presented in the emergency department for edema of the head, neck, eyelids, and upper limbs and dyspnea. The CT scan and CT arteriography showed an obstruction in the venous drainage in the superior vena cava associated with a mediastinal mass, a histotype B malignant thymoma. Therefore, radical surgical resection with correction of the superior vena cava thrombosis was performed. Preoperative transesophageal echocardiography showed pericardial effusion on the inferior apical level with a thickened pericardium. A thrombus was completely occluding the superior vena cava lumen, projecting toward the superior-anterior side of the right atrium, directed toward the right appendage. Cardiopulmonary bypass cannulation was carefully placed using ultrasound guidance to not invade the thrombotic mass, avoiding further embolic events. The postoperative transesophageal echocardiography showed that the thrombus was effectively removed, and the stabilization of the superior vena cava wall was successful. The right appendage was free from thrombosis, similar to the superior vena cava, and pericardial effusion was absent. In this framework, advanced monitoring is fundamental, making neurological, respiratory, and hemodynamic assessments important. As we could not employ the Swan-Ganz catheter given the anatomic obstacle, the transesophageal echocardiographic assessment was mandatory both for hemodynamic monitoring and surgical guidance. It has a role in assessing patients with complete occlusion of the superior vena cava, severe refractory symptoms, and potential thrombosis of venous collaterals. With improved anesthesiology and perioperative advanced monitoring, surgical procedures can be performed safely and effectively in selected patients.