Benign superior vena cava syndrome: Stenting is now the first line of treatment

Management of superior vena cava syndrome during lung transplantation for a patient with cystic fibrosis

Central venous catheters including totally implantable venous access devices (TIVADs) have revolutionised the management of pulmonary infections and exacerbations in patients with cystic fibrosis (CF). While being better tolerated by the patient, these have allowed aggressive intravenous antibiotic therapies during recurrent hospitalisations. Given improvement in procedural strategies and operator experience, many patients with CF undergo lung transplants in the course of their disease nowadays. TIVADs can be associated with thrombosis leading to superior vena cava (SVC) obstruction and SVC syndrome which can pose a challenge, especially during the transplant surgery. We describe a case of successful management of SVC syndrome in a patient with CF undergoing a lung transplant, highlighting the strategies used to minimise risks associated with such a procedure.

Implantation of an arteriovenous graft through the peripheral vascular access in the presence of superior vena cava stenosis but a patent azygos vein: A case report

Long-term indwelling central venous catheters (CVCs) may cause complications, such as central venous disease (CVD). CVD eliminates the possibility of establishing new arteriovenous access. We herein describe a case in which an arteriovenous graft (AVG) is implanted through the peripheral veins and blood flows back to the patent azygos vein, secondary to superior vena cava stenosis. This shows that if the CVD is correctable or the collateral circulation is an alternative vascular pathway that allows blood to return back to the right atrium, the internal fistula flow is well-balanced with the collateral circulation and there are no clinical symptoms of CVD, an arteriovenous access can be established for the operation. This provides a viable, long-term vascular access option for hemodialysis patients with central venous resource depletion.

Outcomes of brachial artery transposition in hemodialysis patients

OBJECTIVE

In hemodialysis patients with a difficult access extremity who are not suitable for an arteriovenous fistula or arteriovenous graft creation, the concept of cannulating a superficialized artery for arterial outflow in dialysis sessions has been adopted as a tertiary alternative. However, its long-term patency and complications have not been recognized widely. We report our 16-year experience with hemodialysis access creation using the brachial artery transposition (BAT) technique.

METHODS

This single-center retrospective study included consecutive patients who underwent BAT for hemodialysis vascular access between June 1, 2006, and December 31, 2022. The patency of the whole access circuit and the transposed brachial artery itself was evaluated independently.

RESULTS

In total, 193 surgical procedures were included. The success rate was 93.2%. The mean operative time was 128 minutes. The median interval from access placement to first cannulation was 21 days. The primary patency rates for BAT were 92.3%, 91.3%, 90.3%, 86.1%, and 71.9% at 1, 2, 3, 5, and 10 years, respectively. The secondary patency rates for BAT were 96.3%, 96.3%, 95.0%, 90.1%, and 74.9% at 1, 2, 3, 5, and 10 years, respectively. The primary patency rates for the whole access circuit were 61.4%, 49.2%, 45.8%, and 26.9% at 1, 2, 3, and 5 years, respectively. The secondary patency rates for the whole access circuit were 85.1%, 83.3%, 82.0%, and 68.6% at 1, 2, 3, and 5 years, respectively. The overall patient survival rates were 79.6%, 69.6%, 54.6%, 36.5%, and 13.4% at 1, 2, 3, 5 and 10 years, respectively. The abandonments of BAT were brachial artery thrombosis (n = 6), pseudoaneurysm (n = 2), aneurysmal change (n = 1), and other reasons (n = 1). The abandonments of the whole access circuit were exhaustion of venous return (n = 26), abandonment of BAT (n = 7), and other reasons (n = 2). Complications were exhaustion of venous return (n = 26), aneurysmal change (n = 12), pseudoaneurysm (n = 6), brachial artery thrombosis (n = 7), impaired wound healing (n = 19), lymphorrhea (n = 9), skin infection (n = 5), hematoma on cannulation (n = 3), and reduced peripheral blood flow (n = 2).

CONCLUSIONS

The patency of BAT was excellent, and that of the whole access circuit was adequate, with a few complications. BAT is an effective alternative from a long-term perspective for patients who are unsuitable for conventional hemodialysis access creation.

Transcatheter stenting of superior vena cava to treat postoperative SVC syndrome in a child: a case report

BACKGROUND

Superior vena cava (SVC) obstruction leading to SVC syndrome is an uncommon but potential complication of cardiac surgeries that involve dissection and anastomosis around the great vein. We present a case of iatrogenic SVC obstruction that was initially treated with transcatheter balloon angioplasty, which provided temporary relief, and ultimately resolved by stenting the affected segment.

CASE PRESENTATION

The index case underwent total anomalous pulmonary venous connection (TAPVC) repair and presented 3 months after surgery with features of SVC obstruction. Initially, transcatheter balloon angioplasty was performed, providing relief from the obstruction; however, the condition recurred within one month. Finally, the patient was treated with percutaneous stenting of superior vena cava, through femoral venous route, using 8 mm × 30 mm balloon-expandable bare metal stent (Formula 418, Cook Medical, Bloomington, IN). Remarkable relief of obstruction was established with decrease in mean gradient across SVC-right atrium junction to 2 mm Hg (from 12 mm Hg before balloon angioplasty and 18 mm Hg before stenting).

CONCLUSION

Percutaneous treatment for iatrogenic SVC obstruction developing after cardiac surgery appears to be effective. Close monitoring is required in the postoperative period for early diagnosis and timely intervention.

Clinical outcomes and predictive factors of stent grafts treatment for symptomatic central venous obstruction in end stage kidney disease patients with arteriovenous access

To assess the efficacy of stent grafts (SGs) in managing central venous obstruction disease (CVOD) in hemodialysis (HD) patients with arteriovenous (AV) access, and to identify predictive factors influencing the SG treatment outcomes. HD subjects with CVOD who underwent SGs placement at our center between August 2018 and June 2022 were enrolled. Survival curve analysis using the Kaplan-Meier method and log-rank test was performed. Cox proportional hazards regression analysis was employed to identify predictive factors associated with outcomes. A total of 59 SG implantation procedures for CVOD were analyzed, comprising 30 cases of stenosis and 29 cases of occlusion. The access circuit primary patency (ACPP) at 6, 12, and 24 months post-SG placement were 80.9%, 53.8%, and 31.4%, respectively, while, the target lesion primary patency (TLPP) were 91.3%, 67.6%, and 44.5%, respectively. Subgroup analysis revealed higher TLPP in the stenosis group compared to the occlusion group, although the difference was not statistically significant (P = 0.165). The TLPP was significantly improved by SG placement in those who had antecedent balloon dilations (P < 0.001). Cox proportional hazards regression identified target lesion length ≥ 30 mm and procedure defects as independent predictors of lower TLPP after SG treatment for CVOD in HD patients. SG placement demonstrates safety and efficacy in managing CVOD among HD patients, leading to improved TLPP of endovascular therapy (EVT) for CVOD. Notably, long target lesions (≥ 30 mm) and procedure defects emerged as predictive factors influencing TLPP.

Percutaneous Image-Guided Treatment of Pediatric Deep-Vein Occlusions

Pediatric venous occlusions are a growing cause of morbidity and mortality, especially in hospitalized patients. Catheter-directed recanalization is a safe and effective treatment option in appropriately selected patients. Benefits of catheter directed therapies (CDTs) include the prevention of pulmonary embolism and end organ failure acutely as well as superior vena cava syndrome and post-thrombotic syndrome chronically. Timely diagnosis, recognition of underlying factors for thrombosis, and familiarity with the spectrum of tools and techniques for CDT are essential to optimizing outcomes in the acute setting. Recanalization of chronic venous occlusions can similarly provide symptomatic relief and achieve long term vessel patency. This review will detail the scope, techniques, and outcomes for CDT in the treatment of acquired systemic deep vein occlusions.

Cavoatrial junction stenting in vascular hemodialysis catheter malfunction

In patients undergoing hemodialytic treatment via intravascular catheters, stenosis or occlusion of central veins is common. Despite an extensive characterization of Superior Vena Cava Syndrome (SVCS) no data is available about CavoAtrial Junction (CAJ) stenosis. We report the case of two patients with a story of multiple catheter failures due to thrombosis or infection. Computed tomography (CT) showed radiological signs of CAJ stenosis confirmed at the following venography. In absence of other feasible options to place a vascular access, the two underwent stenting with Gore Viabahn VBX balloon expandable endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA) of the CAJ stenosis. Completion venography showed complete resolution of the stenosis in both patients. No complications occurred during the procedures. At a mean follow-up of 878 ± 559 days no signs of in-stent restenosis or recoil were found. The present cases emphasize the feasibility and safety of CAJ stenting, underlining the importance of preserving CAJ and upper veins patency in hemodialysis access.

Management of cerebrospinal fluid rhinorrhea as a rare complication of antiphospholipid syndrome

Background

Antiphospholipid syndrome is a complex autoimmune condition associated with the formation of recurrent thrombosis in any vascular bed throughout the body. Jugular vein thrombosis is very rare with only a 0.9% occurrence and is not typically associated with cerebrospinal rhinorrhea as a result of raised intracranial pressure.

Case Description

A 54-year-old patient presented with a 9-month history of cerebrospinal fluid (CSF) rhinorrhea and headache on a background of antiphospholipid syndrome. Investigations showed a superior vena cava (SVC) and right internal jugular vein (IJV) obstruction with moderately elevated intracranial venous pressures. Her magnetic resonance imaging (MRI) brain was consistent with a CSF leak. The patient underwent successful endovascular stenting of her obstructed SVC and right IJV followed by surgical repair of a herniating meningocele in the posterior left ethmoid air cells.

Conclusion

CSF rhinorrhea is uncommon and never previously reported associated with SVC thrombosis induced by antiphospholipid syndrome. A combination of endovascular techniques and surgical repair is recommended for this challenging presentation.

Transcatheter management of superior vena cava obstruction following cardiac surgery: A case report from a resource-limited set-up

Obstruction of the superior vena cava (SVC) is a rare complication after cardiac surgery in infants and children. We present the case of an 8-year-old boy who underwent bi-directional Glenn shunt followed by takedown of Glenn shunt and complete repair for cyanotic congenital heart disease. After 4 years of surgery, the child developed features of superior vena caval (SVC) syndrome. Echocardiography and CT angiography revealed complete obstruction of SVC without any forward flow. Transcatheter intervention was performed successfully to re-canalize and stent the SVC to maintain its patency. The patient was doing well at follow-up appointments, with good laminar flow through the stent. In conclusion, transcatheter management of post cardiac surgery SVC obstruction was successful in this patient.

Management with right atrium to jugular and brachiocephalic vein bypass for dialysis catheter-related superior vena cava syndrome

Superior vena cava (SVC) syndrome is a spectrum of potentially life-threatening clinical manifestations resulting from either partial or complete obstruction of central venous blood flow. Approximately 70% of cases are caused by malignancy. The primary treatment end point for SVC syndrome is the achievement of long-term patency of the SVC. Malignant SVC syndrome is managed by either radiation therapy, open surgical intervention, or endovascular therapy with angioplasty and stenting. The current report describes an uncommon case of nonmalignant SVC syndrome resulting from complications of hemodialysis catheters that was managed with open revascularization between the right internal jugular and brachiocephalic veins and the right atrium.

Using Fenestrated Stent to Increase the Flow of Extracorporeal Membrane Oxygenation of Superior Vena Cava Compression Syndrome

Superior vena cava syndrome (SVCS) is an obstruction of the venous return through the superior vena cava (SVC) or any other significant branches. The obstruction may be external, like thoracic mass compressing the SVC, or internal, like thrombosis or tumor, which directly invades the SVC. Patients experiencing a medical emergency after being initially stabilized require treatment for SVCS, including endovenous recanalization and the implantation of an SVC stent to reduce the risk of abrupt respiratory arrest and death. A 54-year-old female presented from the university medical center with weight loss and solid food dysphagia for three months. Chest-CT scan showed a mediastinal mass of 10 x 9 x 8 cm. A transbronchial biopsy was attempted. The patient was arrested during the bronchoscopy lab procedure. Cardiopulmonary resuscitation (CPR) was initiated, and venoarterial-extracorporeal membrane oxygenation (VA-ECMO) was done through the right femoral artery cannula size 15 Fr due to the narrowing of the artery and the left femoral vein cannula size 23 Fr. During the night shift, the ECMO flow was hard to maintain with fluids, which was realized with the ECMO outflow volume issue. The next day, in the hybrid operating room, a fenestrated SVC stent was placed in the SVC, brachiocephalic, and internal jugular veins. The patient's hemodynamics improved post-stenting, especially ECMO outflow. This case illustrates that stenting in SVCS is a valid therapeutic option to increase the ECMO flow in this patient group.

Superior Vena Cava Syndrome: An Umbrella Review

Superior vena cava syndrome (SVCS) is a medical emergency that encompasses an array of signs and symptoms due to obstruction of blood flow through the superior vena cava (SVC). It poses a significant healthcare burden due to its associated morbidity and mortality. Its impact on the healthcare system continues to grow due to the increasing incidence of the condition. This incidence trend has been attributed to the growing use of catheters, pacemakers, and defibrillators, although it is a rare complication of these devices. The most common cause of SVCS remains malignancies accounting for up to 60% of the cases. Understanding the pathophysiology of SVCS requires understanding the anatomy, the SVC drains blood from the right and left brachiocephalic veins, which drain the head and the upper extremities accounting for about one-third of the venous blood to the heart. The most common presenting symptoms of SVCS are swelling of the face and hand, chest pain, respiratory symptoms (dyspnea, stridor, cough, hoarseness, and dysphagia), and neurologic manifestations (headaches, confusion, or visual/auditory disturbances). Symptoms generally worsen in a supine position. Diagnosis typically requires imaging, and SVCS can be graded based on classification schemas depending on the severity of symptoms and the location, understanding, and degree of obstruction. Over the past decades, the management modalities of SVCS have evolved to meet the increasing burden of the condition. Here, we present an umbrella review providing an overall assessment of the available information on SVCS, including the various management options, their indications, and a comparison of the advantages and disadvantages of these modalities.

Acute venous problems: Integrating medical, surgical, and interventional treatments

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

Percutaneous thrombectomy of upper extremity and thoracic central veins using Inari ClotTriever System: Experience in 14 patients

Objective

In the present report, we have described the technical and clinical outcomes of percutaneous thrombectomy in the deep veins of the upper extremity and thorax using the ClotTriever system (Inari Medical, Irvine, CA).

Methods

Fourteen patients with symptomatic deep venous occlusive disease in the upper extremity deep veins and thoracic central veins who had undergone thrombectomy using the ClotTriever system between October 2020 and January 2022 were reviewed. The technical results, adverse events, imaging follow-up data, and clinical outcomes were recorded.

Results

Fourteen patients (seven men and seven women; mean age, 53.6 ± 13.3 years) constituted the study cohort. Of the 14 patients, 9 (64.3%) had had DVT due to intravascular invasion or external compression from known malignancy, 2 (14.3%) had had infected thrombi and/or vegetation due to Staphylococcus aureus refractory to intravenous antibiotic therapy, and 3 (21.4%) had had a benign etiology for thrombus formation. The presenting symptoms included upper extremity and/or facial swelling (n = 14), upper extremity pain (n = 6), fever (n = 2), and dyspnea (n = 1). Thrombectomy with the ClotTriever system was successfully completed in all 14 patients. Seven patients (50.0%) had required additional venous stent reconstruction after thrombectomy to address the underlying stenosis. No major adverse events were noted. All the patients had experienced resolution of the presenting symptoms.

Conclusions

For the management of symptomatic deep venous occlusive disease of the upper extremity deep veins and thoracic central veins, thrombectomy using the ClotTriever system was feasible with excellent technical and clinical success.

Kissing Viabahn VBX stent graft reconstruction of thoracic central veins for management of superior vena cava syndrome

OBJECTIVE

In the present study, we evaluated the technical and clinical outcomes of thoracic central vein reconstruction for superior vena cava (SVC) syndrome using kissing Viabahn VBX stent grafts (W.L. Gore & Associates, Flagstaff, AZ).

METHODS

All adult patients with SVC syndrome who had undergone attempted bilateral brachiocephalic vein-to-SVC reconstruction using kissing VBX stent grafts at an academic hospital between August 2019 and February 2021 were reviewed. The technical results, adverse events, imaging follow-up findings, and clinical outcomes were recorded. Patency over time was assessed using Kaplan-Meier analysis.

RESULTS

A total of 28 patients (16 women and 12 men; mean age, 52.0 years) constituted the study cohort. Of the 28 patients, 17 (60.7%) had had benign and 11 (39.3%) malignant etiologies. The presenting symptoms included neck swelling (n = 17; 60.7%), bilateral upper extremity swelling (n = 15; 53.6%), dyspnea (n = 7; 25%), unilateral upper extremity swelling (n = 4; 14.3%), and dysphagia (n = 1; 3.6%). SVC reconstruction with VBX stent grafts in a kissing configuration was successfully completed in 27 of the 28 patients (96.4%). Four major adverse events were noted in the benign etiology subgroup (23.5%), including intraprocedural hemopericardium (n = 3) and delayed pneumothorax (n = 1). Of the 28 patients, 27 (96.4%) had experienced resolution of their presenting symptoms. The mean clinical follow-up for the living patients was 358.8 ± 77.2 days (range, 78-645 days). The mean imaging follow-up for the living patients was 272.6 ± 91 days (range, 26-594 days). The primary, primary-assisted, and secondary patency rates at 12 months were 71.8%, 88.8%, and 100%, respectively.

CONCLUSIONS

For the management of SVC syndrome, thoracic central vein reconstruction with kissing VBX stent grafts was feasible with a high rate of symptom resolution and acceptable patency. However, this technique should not be recommended for those with benign SVC syndrome owing to the high risk of cardiac tamponade.

Catheter-directed thrombectomy with the JETi8 in the treatment of acute superior vena cava syndrome

Superior vena cava syndrome can lead to significant morbidity and mortality, particularly in acute settings. We report a case of an acute Port-a-Cath-associated thrombosis of the superior vena cava. Percutaneous catheter-directed thrombectomy was performed using the JETi8 thrombectomy device with additional angioplasty and stenting, allowing rapid flow restoration and rapid clinical recovery. Postoperative anticoagulation was initiated and pursued lifelong. This report is unique in illustrating how JETi8 thrombectomy seems to be a safe and effective therapy, allowing rapid flow restoration, rapid clinical improvement, and persistent patency at 6 months.

Superior Vena Cava Syndrome Due to Right Anterior Mediastinal Hematoma: A Case Report

The superior vena cava syndrome (SVCS) has been frequently reported to be secondary to malignancy, specifically, small cell bronchogenic carcinoma and non-Hodgkin's lymphoma. There is some data suggesting causes like postprocedural hematomas. We aim to describe a case of a patient who developed SVCS secondary to a mediastinal hematoma secondary to epicardial pacer leads (postprocedural).

Our case is about a 75-year-old male with a past medical history of coronary artery disease and coronary artery bypass graft (CABG) who presented to the Emergency Department (ED) with moderate-to-severe right axillary pain radiating to the ipsilateral side of the neck, arm, and chest, associated to right temporal headache. A computed tomography angiography (CTA) of the chest was indicated at the time and revealed a hematoma with an active extravasation within the right superior anterior mediastinum, outside the pericardium. The patient was admitted to the Cardiovascular Intensive Care Unit (CVICU) and was started on nicardipine as his blood pressure in the ED was 217/125 and remained elevated despite proper pain management. A repeat CT scan of the chest showed a regressing hematoma that coincided with an improvement of the symptoms.

This case highlights the importance of the complications of anterior mediastinal hematoma. The superior vena cava syndrome can develop after cardiologic procedures, after the implantation of devices. Prompt clinical diagnosis, including imaging, and treatment are necessary to manage this condition.

Superior Vena Cava Syndrome: Etiologies, Manifestations, and Treatments

Superior vena cava (SVC) obstruction, whether from benign or malignant causes, results in a variety of symptoms. It is a potential medical emergency when cerebral or laryngeal edema occurs. Endovascular therapy is the treatment of choice for patients in need of emergent relief of symptoms. This article will provide a review of SVC syndrome with a focus on endovascular treatment techniques.

Right subclavian artery to right atrium bypass using Polytetrafluoroethylene (PTFE) graft in hemodialysis patient with central venous occlusion: Case report

Introduction

Case presentation

Clinical discussion

Conclusion

•

Central venous Occlusion (CVO) is a serious complication which occurs mainly in patients with chronic indwelling central venous catheters for dialysis.

•

We report the case of a patient with end-stage Kidney disease (ESKD), who was admitted for chronic occlusion of the superior and inferior vena cava. So she underwent a right subclavian artery to right atrium (RA) bypass using polytetrafuloroetylene (PTFE) graft.

•

Bypass to RA by mini thoracotomy insision is rarely performed, and remains the last ditch resort to preserve adequate vascular access in hemodialysis patients with central venous occlusion.

•

Fistulas as a first approach for dialysis access must be privileged at the expense of central catheters to prevent CVO.

Lead-Related Venous Obstruction in Patients With Implanted Cardiac Devices: JACC Review Topic of the Week

Cardiac implantable electronic device implantation rates have increased in recent decades. Venous obstruction of the subclavian, brachiocephalic, or superior vena cava veins represents an important complication of implanted leads. These forms of venous obstruction can result in significant symptoms as well as present a barrier to the implantation of additional device leads. The risk factors for the development of these complications remain poorly understood, and diagnosis relies on clinical recognition and cross-sectional imaging. Anticoagulation remains the mainstay of treatment, and thrombus debulking, lead extraction, venoplasty, and stenting are all important therapeutic interventions. This review provides a multidisciplinary-based approach to the evaluation and management of cardiac implantable electronic device lead-associated venous obstruction.

Venous stent versus conventional stent for the treatment of central vein obstruction in hemodialysis patients: a retrospective study

BACKGROUND

Endovascular treatment is a first-line treatment for upper thoracic central vein obstruction (CVO). Few studies using bare venous stents (BVS) in CVO have been conducted.

PURPOSE

To evaluate the treatment performance of upper thoracic central vein stenosis between BVS and conventional bare stent (CBS) in hemodialysis patients.

METHODS

Hemodialysis patients with upper thoracic central vein obstruction who underwent endovascular treatment at the interventional unit of our institution from 1 January 2008 to 31 December 2018 were enrolled in the present study. CBS was used to treat central vein obstruction in 43 patients and BVS in 34 patients. We compared the primary patency rates and complications between the two stent types. P values < 0.05 were considered statistically significant.

RESULTS

The patient demographic data between the CBS and BVS groups were similar. The characteristics of the lesions, procedures, and complications were not significantly different between the two groups (P > 0.05). There were no statistically significant differences of primary patency rates at three and six months between the BVS and CBS groups (94.1% vs. 86.0% and 73.5% vs. 58.1%, respectively; P > 0.05). The primary patency rate at 12 months in the BVS group was significantly higher than that in the CBS group (61.8% vs. 32.6%; P = 0.008).

CONCLUSION

Endovascular treatment of central vein obstruction with BVS provided a higher primary patency rate at 12 months than CBS.

Open surgical treatment of superior vena cava syndrome due to invasive thymoma

Here we describe a case of open surgery for superior vena cava syndrome due to invasive thymoma. An 85-year-old woman presented with facial swelling and exertional dyspnea. Computed axial tomography revealed a thymoma in the mediastinum, extending to the superior vena cava, right atrium, and bilateral brachiocephalic veins. Endovascular therapy did not seem feasible because superior vena cava appeared totally occluded, and stenting could cause tumor embolism to the pulmonary arteries. Open surgery facilitated macroscopically complete and successful tumor resection. If long-term survival seems possible, open surgery could be a viable treatment option for superior vena cava syndrome that is ineligible for endovascular therapy.

Endovascular Stenting in Superior Vena Cava Syndrome: A Systematic Review and Meta-analysis

PURPOSE

Endovascular stenting has been used to manage superior vena cava syndrome for several decades and has become standard firstline practice. This study aims to investigate the outcomes of endovascular stenting in the management of superior vena cava syndrome (SVCS).

METHODS

MEDLINE, EMBASE and PUBMED online databases were searched, with studies involving more than ten adult patients included. Studies identified spanned 27 years, from 1993 to 2020. Meta-analyses were performed based on Clopper-Pearson estimation.

RESULTS

Fifty-four studies were identified, for a total of 2249 patients, of which 2015 had malignant SVCS and 222 benign SVCS. Pooled technical success and clinical success rates were 96.8% (95% CI 96.0-97.5%) and 92.8% (95% CI 91.7-93.8%). Technical success and clinical success rates for studies investigating benign SVCS alone were identical at 88.8% (95% CI 83.0-93.1%). Pooled patency remained above 90% for the first year. Average complication and re-intervention rates were 5.78% (SD = 9.3182) and 9.11% (SD = 11.190).

CONCLUSIONS

This review confirms the effectiveness of endovascular stenting in managing SVCS. Further directions of research may include specific outcomes of endovascular stenting in benign SVCS, and the impact of procedural characteristics, such as the use of anticoagulation and type of stent used, on outcomes.

LEVEL OF EVIDENCE

Level III, systematic review of retrospective cohort studies.

Insights Into Endovascular Management of Superior Vena Cava Obstructions

Superior vena cava obstruction results from any limitation of blood flow through the superior vena cava. Circulation to the heart may persist through various collateral vessels whose development depends on the level of obstruction. Depending on the level and degree of occlusive disease, the severity of clinical symptoms may vary considerably, up to lethal. Etiologies have changed dramatically in recent years, mainly due to the increasing use of intravascular devices. However, guidelines for treatment are lacking, and various options are available. Endovascular therapies developed considerably in recent years, may offer a rapid improvement in symptoms and proved to be safe. However, knowledge and selection of appropriate techniques are essential to venous angioplasty, involving specific tools to guarantee satisfying outcomes. This review aims to discuss the particular venous anatomy of the upper body, the physiopathology of superior vena cava obstruction, and specificities of endovascular treatment compared with other management options.

Superior Vena Cava Syndrome

Superior vena cava (SVC) syndrome comprises a constellation of clinical signs and symptoms caused by obstruction of blood flow through the SVC. The management of patients with life-threatening SVC syndrome is evolving from radiation therapy to endovascular therapy as the first-line treatment. There is a paucity of data and societal guidelines with regard to the management of SVC syndrome. This paper aims to update the practicing interventionalists with the contemporary and the evolving therapeutic approach to SVC syndrome. In addition, the review will focus on endovascular techniques, including catheter-directed thrombolysis, angioplasty, and stenting, and their associated complications.

Endovascular therapy for superior vena cava syndrome: A systematic review and meta-analysis

BACKGROUND

Superior vena cava (SVC) syndrome is caused by the obstruction of the SVC and can result in significant morbidity and mortality. In contemporary practice, endovascular therapy (ET) has become the standard of care for a majority of these patients. This study is a systematic review and meta-analysis of the available literature to assess technical success, restenosis, and recurrence of SVC syndrome following endovascular intervention.

METHODS

For this meta-analysis, we conducted a systematic literature review of PubMed, Cochrane Library, and Embase databases from inception to April 14, 2021 for studies on ET for SVC syndrome. Studies included full-length journal articles on the use of ET among adults with SVC syndrome. Case reports or case series with fewer than 20 patients were excluded. We evaluated the endpoints of technical success rate, restenosis rate, and recurrence rates in SVC syndrome patients after endovascular stenting. The results of this study were calculated using random-effects models.

FINDINGS

We identified 6,012 reports, of which 39 studies met our inclusion criteria and were included for analysis. A total of 2200 patients received ET for SVC syndrome. The weighted technical success rate was 98.8% (95% CI 98.2-99.3) with low heterogeneity (I²=17.4%, p = 0.185), restenosis rate was 10.5% (95% CI 8.4-12.6) with moderate heterogeneity (I²=53.5%, p<0.001), and recurrence rate was 10.8% (95% CI 8.1-13.5) with high heterogeneity (I²=75.8%, p<0.001). Total complication rate was 8.6% (95% CI 7.3%-9.9%) with a mean complication rate of 7.5% (95% CI 4.7%-10.3%).

INTERPRETATION

Our systematic review revealed high technical success, low restenosis, and low recurrence rates following ET. Collectively, these results support the paradigm of ET as an effective and safe treatment for patients with SVC syndrome.

FUNDING

None.

Long Term Results of Bypass Graft to the Right Atrium in the Management of Superior Vena Cava Syndrome in Dialysis Patients

BACKGROUND

Superior vena cava (SVC) occlusion in dialysis patients is a serious complication that can cause SVC syndrome and vascular access dysfunction. While endovascular therapy has advanced to become the first line of treatment, open surgical treatment may still be needed occasionally. However, no long term outcome data has been previously reported.

METHODS

We performed a retrospective review of 5 dialysis patients treated with bypass graft to the right atrium from 2012 to 2014. Four patients had severe dysfunction of their upper arm dialysis access as well as superior vena cava syndrome, and one patient with a femoral tunneled dialysis catheter (TDC) had SVC occlusion. None of the patients were candidates for lower extremity access creation or peritoneal dialysis (PD). Three patients underwent a left brachiocephalic-right atrial bypass and 2 underwent a bypass from the cephalic fistula to the right atrium.

RESULTS

All procedures were technically successful and maintained function of the arteriovenous fistulas or allowed creation of a new upper extremity dialysis graft. One-year secondary patency rate of the bypass was 100%. Longer follow up revealed that one patient died of leg sepsis and another one of a stroke within 14 months after the procedure. Another patient did well for 16 months when recurrent graft thrombosis occurred; and ultimately the graft failed after 31 months despite multiple interventions. Two patients maintained bypass graft patency during a follow up of 78 months; however, they underwent multiple endovascular interventions (23) and open vascular access procedures (4) to maintain hemodialysis function.

CONCLUSION

Bypass grafts to the right atrium in dialysis patients with SVC occlusion are successful in maintaining function of already existing vascular access or new ones. Long term secondary patency can be achieved but requires strict follow up and a proactive endovascular strategy to treat lesions in the access and or the bypass graft.

Management of Superior Vena Cava Occlusion Causing Bleeding "Downhill" Esophageal Varices

The health care system in Peru treats 15,000 dialysis patients annually. Approximately 45% of patients receive therapy using catheters. The incidence of catheter-induced superior vena cava (SVC) occlusion is increasing along with its associated significant morbidity and vascular access dysfunction. One of the unusual manifestations of this complication is bleeding "downhill" esophageal varices caused by reversal of blood flow through esophageal veins around the obstruction to the right atrium. Herein is presented the case of an 18-year-old woman on hemodialysis complicated by SVC occlusion and bleeding esophageal varices who underwent successful endovascular recanalization of the SVC. Bleeding from "downhill" esophageal varices should be considered in the differential diagnosis of dialysis patients exposed to central venous catheters. Aggressive endovascular treatment of SVC occlusion is recommended to preserve upper extremity access function and prevent bleeding from this complication.

Combined cut down and endovascular retrieval of orphaned ventriculoatrial shunt with stenting of chronic superior vena cava occlusion

Revascularization of the superior vena cava (SVC) in the context of symptomatic luminal obstruction is a therapeutic intervention performed for SVC syndrome of benign or malignant etiology. Venous occlusion can preclude future access and cause symptoms ranging from mild chest discomfort to the more serious effects of SVC syndrome. This case report demonstrates the treatment of a novel case of SVC syndrome arising from a previously placed SVC stent. An intravascular, extraluminal orphaned ventriculoatrial shunt was used to go through the SVC but around the existing lumen-limiting stent to place a new larger stent for revascularization. This case highlights the need for an innovative approach for complex foreign body retrieval and treatment of chronic SVC occlusion.

Tuberculosis lymphadenopathy: A rare etiology of the superior vena cava syndrome

Superior vena cava syndrome is the clinical expression of the obstruction of the superior vena cava reducing the blood flow. Malignant etiologies are the most common. Its management is multidisciplinary and despite the progress of endovascular procedures, conventional surgery retains its place in certain indications. Mediastinal fibrosis secondary to tuberculosis lymphadenopathy may be associated with superior vena cava syndrome. In the presence of symptomatic SVCS associated with extensive mediastinal fibrosis compressing the superior vena cava with sub occlusive thrombosis, conventional surgery remains a treatment option, with cavo-venous derivation by prosthetic bypass.

Managing systemic venous occlusions in children

Pediatric venous disease is increasing in incidence in both inpatient and outpatient populations. The widespread use of central venous access devices as well as the rising incidence of thromboembolic events in pediatrics is leading to more systemic venous occlusions in both the central and peripheral veins. This review focuses on the etiology, presentation, workup, and general technical considerations of recanalization as well as procedural complications related to pediatric systemic venous occlusive disease. The potential role for pediatric interventional radiology guided treatments will be discussed in detail.

Outcome of stenting in central venous obstruction of benign etiology

Background: The aim of this study is to evaluate long term outcome in patients treated for benign superior vena cava (SVC) syndrome by endovascular techniques. Patients and methods: Between 2015 and 2018, 62 patients suffering from central venous obstruction of benign etiology underwent balloon angioplasty with stent placement for venous obstruction in our department. Patency was assessed clinically, using duplex ultrasound in all patients or with CT-phlebography in selected cases. Results: Median age was 60 years (23-83), forty-one patients (66%) had central venous devices. Swelling of the arm and face were the main symptoms (71%). During the median follow up of 22 months (9-38), cumulative primary patency was 71% after venous stenting. The cumulative assisted primary and the secondary patency were 85% and 92%, respectively. Conclusions: Recanalization and stenting of central vein obstruction has turned out to be the technique of reference and provides satisfactory mid-term patency rates. After adjusting for the risk factors, presence of AV-fistula remained a significant risk factor for recurrent stenosis or loss of patency after intervention.

Endovascular treatment of type 3 and 4 thoracic central vein obstruction in hemodialysis patients

OBJECTIVE

Thoracic central vein (TCV) obstruction (TCVO) in the presence of upper extremity (UE) hemodialysis access can present as superior vena cava syndrome (SVCS) and cause vascular access dysfunction and failure. We report the techniques and results of endorevascularization of TCVO in hemodialysis patients, which allowed for long-term functioning vascular access in the UE.

METHODS

From June 2009 to February 2020, 45 hemodialysis patients underwent TCV endorevascularization. The indications for surgery were TCVO or SVCS that threatened the function of a preexisting upper arm access or contraindicated placement of a new upper arm access. Conventional endovascular techniques were used when feasible. Patients with unfavorable anatomy were treated using a transseptal needle to cross difficult intrathoracic stenosis and occlusions or to facilitate an inside-out central venous access technique. The reestablishment of venous outflow was accomplished with angioplasty, stenting, and/or placement of HeRO conduits. Successful revascularization was followed by hemodialysis access revision or a new UE access placement. We recorded the risk factors and procedural outcomes, patency rates, complications, and mortality.

RESULTS

The mean age was 53 ± 16.3 years, and 51% were women. The most common risk factors were diabetes mellitus (64.2%) and hypertension (56%). Twenty-five patients (55.5%) had symptoms of SVCS. These symptoms resolved after the TCV procedure in all cases. Crossing of the TCV lesion was successful using a conventional catheter and wire in 26 cases (57.8%) and transseptal needle in 17 cases (37.8%), including 12 using an inside-out central venous access technique. Treatment of the TCV lesion included a HeRO conduit in 20 cases (44.4%), stenting in 17 (37.7%), and transluminal balloon angioplasty alone in 7 (15.5%). Other veins were treated in 33 cases (73.3%). The overall technical success rate was 95.5%. Two intraoperative complications occurred, including one case of severe hypotension and one of fatal cardiac tamponade. Of the 16 patients with preexisting UE access, its function was preserved in all 16 (100%). In 24 of 27 patients (85.7%), new arm access was successfully created after the TCV procedure. The overall clinical success rate was 88.9%. The average follow-up was 663.4 days (median, 507 days; range, 0-2679 days). During follow-up, 26 patients had undergone 90 procedures to maintain access function, 21 had undergone repeat endovascular interventions, and 17 had undergone open procedures. Eight patients (17.8%) had developed infection, five involving HeRO conduits that required excision with loss of access. During the follow-up period, 14 patients (31%) had died of unrelated causes, and 34 patients (75.5%) maintained functional access.

CONCLUSIONS

The results of the present study have shown that endorevascularization of TCVO reconstruction is effective in maintaining function or allowing the creation of UE hemodialysis access, with acceptable complication rates.

Endovascular treatments of tunneled central venous catheter-induced superior vena cava complete occlusion via through-and-through technique

BACKGROUND

Superior vena cava occlusion (SVCO) induced by tunneled central venous catheter (tCVC) is an uncommon but challenging complication of hemodialysis patients. The aim of this study was to access the efficacy, safety, and patency of stents in tCVC-related SVCO via through-and-through technique.

METHOD

We retrospectively identified seven patients with benign SVCO secondary to tCVC treated with endovascular approaches successfully between 1 March 2013 and 31 October 2019. Patients' demographic data, clinical signs and symptoms, and imaging data were followed up and recorded.

RESULTS

Technical success was achieved in all cases. All the patients were performed with percutaneous transcatheter angioplasty (PTA) and subsequently stent placement via the through-and-through technique. During follow-up, four patients underwent secondary interventions, including PTA and/or stent placement. The primary patency after 3, 6, 9 and 12 months was 100%, 100%, 86% and 86%, and secondary patency after 12 months was 100%. No procedure-related deaths occurred.

CONCLUSIONS

Endovascular management of SVCO is a safe and effective approach. CT examination can provide a direction for endovascular treatment and periodic surveillance.

Diathermy-assisted recanalization of chronic superior vena cava obstruction, case report

The number of cases of superior vena cava syndrome (SVCS) increased due to increased cardiac devices and central venous catheters. Management of benign SVCS is still controversial. A 51-year-old male known to have ischemic cardiomyopathy and chronic renal failure on regular hemodialysis. In the last 12 months, he had progressive shortness of breath and swelling of his upper part of the body. Examination revealed engorgement of the neck veins, facial puffiness, and pitting edema of both upper limbs. Venography showed occluded SVC. We applied a 50 Watt of energy via electrocautery pen to a Hi-Torque 0.014 Astato guidewire to cross the occluded segment retrogradely. We used 2 stents 39 mm, mounted on BIB 20/40 mm. Final angiography revealed full restoration of SVC flow. Diathermy use to cross a chronic total SVC obstruction is feasible and safe. Endovascular techniques are suitable as initial management of benign SVC syndrome.

A retrospective stenting study on superior vena cava syndrome caused by lung cancer

Background

Superior vena cava syndrome (SVCS) is a common condition predominantly caused by lung cancer. The presence of symptoms of SVCS, such as elevated intracranial pressure and laryngeal edema, indicates an unfavorable prognosis for lung cancer patients. Superior vena cava (SVC) stenting is the first‐line treatment for SVCS. In this study, we retrospectively analyzed SVCS cases treated with stenting in our center to explore the safety and effectiveness of stenting in the treatment of SVCS.

Methods

We reviewed 16 patients with SVCS caused by lung cancer who were treated at our center with endovascular stenting between 2016 and 2018. Patient information such as age, sex, type of lung cancer, obstruction condition, complications, survival time, and postoperative treatments are summarized.

Results

There were no treatment‐related complications in the perioperative period in any of the patients. Examination at postoperative day 2 indicated that the accompanying SVCS symptoms had improved in all patients. The median survival of patients treated along with combined postoperative chemotherapy and antivascular targeted therapy reached seven months (1–18 months).

Conclusions

SVC stenting is effective as a first‐line treatment modality for patients with SVCS caused by lung cancer. In combination with other treatment modalities, it can significantly alleviate symptoms and reduce complications, and thus it plays an important role in the treatment of patients with SVCS caused by lung cancer.

Superior vena cava stenting in IgG4-associated mediastinal fibrosis

We report a rare case of IgG4-associated mediastinal fibrosis with complete superior vena cava (SVC) obstruction successfully managed by thrombolysis and stenting in a 33-year-old male. The patient presented with a mediastinal mass lesion with clinical findings of SVC obstruction. Surgical biopsy of the mediastinal mass lesion with histology and immunohistochemistry staining established the diagnosis of IgG4 associated mediastinal fibrosis. The patient was treated with a systemic steroid and rituximab, but despite treatment, SVC obstruction and thromboses persisted, surgical intervention was declined by the thoracic surgeon due to extensive mediastinal fibrosis and an expected poor outcome. Percutaneous SVC angioplasty, intravascular thrombolysis with tissue plasminogen activator and afterward stent placement was done by the interventional radiology service. This intervention is rare and possibly was lifesaving as it restored complete patency of the SVC. Our case is probably the first with IgG4 mediastinitis and SVC complete obstruction relieved by intravascular thrombolysis and SVC stent placement. It demonstrates that SVC stenting can relieve SVC obstruction in patients with a high risk of surgery either due to medical comorbidities or an expected high surgical risk like bleeding in the mediastinal fibrosis, which in our case of SVC obstruction was due to a nonoperable mediastinal tumor. SIMILAR CASES PUBLISHED: None to our knowledge.

A review of endovascular stenting for superior vena cava syndrome in fibrosing mediastinitis

Fibrosing mediastinitis (FM) is a rare disorder of inflammation and fibrosis involving the mediastinum. The formation of fibroinflammatory mass in the mediastinum can lead to obstruction of mediastinal structures and cause severe debilitating and life-threatening symptoms. Superior vena cava syndrome (SVCS) is a dreaded complication of FM with no medical therapy proven to be efficacious. Spiral vein grafting has long been utilized as first-line therapy for SVC syndrome due to FM. Endovascular repair with stents and angioplasty for malignant causes of SVC syndrome is well established. However, there are limited data on their utility in SVC syndrome due to FM. We present two cases of SVC syndrome due to FM treated with endovascular stenting and a detailed review of current literature on its utility in SVCS due to benign causes.

Early experience of transcatheter correction of superior sinus venosus atrial septal defect with partial anomalous pulmonary venous drainage

AIMS

Superior sinus venosus atrial septal defect (SVASD) is commonly associated with partial anomalous pulmonary venous drainage (PAPVD). We aimed to describe the first series of percutaneous SVASD and PAPVD correction using a two-step simulation for procedural planning.

METHODS AND RESULTS

Patients with SVASD and right PAPVD with a clinical indication for correction were selected. They underwent an ex vivo procedural simulation on a 3D-printed model followed by an in vivo simulation using balloon inflation in the targeted stent landing zone. The percutaneous procedure consisted in deploying a 10-zig custom-made covered stent in the SVC-RA junction. Five patients were referred for preprocedural evaluation and were deemed suitable for percutaneous correction. The procedure was successful in all patients with no residual interatrial shunt and successful redirection of the pulmonary venous drainage to the left atrium. At a median clinical follow-up of 8.1 months (2.6-19.8), no adverse events were noted, and all patients showed clinical improvement. During follow-up, transthoracic echocardiography and multidetector cardiac tomography in four patients or invasive angiography in one patient demonstrated a patent SVC stent, and no residual SVASD and unobstructed PV drainage in all patients.

CONCLUSIONS

In selected patients using a two-stage simulation strategy, percutaneous correction of SVASD with PAPVD is feasible and safe, and led to favourable short-term outcomes.

Total Endovascular Repair of Post-Trauma Ascending Aortic Pseudoaneurysm and Secondary Superior Vena Cava Syndrome

BACKGROUND

Clavicular fracture or sternoclavicular luxation is observed in 10% of all polytrauma patients and is frequently associated with concomitant intrathoracic life-threatening injuries. Posterior sternoclavicular luxation is well known to induce underlying great vessels damage. The gold standard treatment usually is a combined orthopedic and cardiovascular surgical procedure associating vascular repair, clavicular open reduction, and internal fixation.

METHODS

A 59-year-old wheelchair ridden, institutionalized woman, known for psychiatric disorder, severe scoliosis, malnutrition, and chronic obstructive pulmonary disease was admitted in our hospital for chronic chest pain 3 months after a stairway wheelchair downfall. A thoracic computed tomography (CT) scan revealed a voluminous ascending aortic pseudoaneurysm (63 × 58 mm, orifice 5 mm) consecutive to perforation following posterior sternoclavicular luxation. The patient refused all therapies and was lost to follow-up. Six months later, she was readmitted for a symptomatic superior vena cava syndrome. Thoracic CT scan revealed pseudoaneurysm growth with innominate vein thrombosis and superior vena cava subocclusion. Pseudoaneurysm orifice was stable. In the presence of symptoms with massive facial edema and inability to open her eyelids, the patient accepted an endovascular treatment.

RESULTS

The procedure was performed under general anesthesia using both fluoroscopic and transesophageal echocardiographic guidance. Through a femoral arterial access, a 10-mm atrial septal defect occluder device was used to seal successfully the pseudoaneurysm orifice. The superior vena cava was then opened with a 26-mm nitinol high radial force stent through a femoral venous access. Postoperative course was uneventful. At 3-month follow-up, the patient remains symptom free and a CT scan confirmed pseudoaneurysm thrombosis and superior vena cava permeability.

CONCLUSION

Post-traumatic sternoclavicular posterior luxation is a cause of great vessels and ascending aorta injuries. Minimally invasive endovascular approaches can be considered to treat vascular injuries and their consequences, especially in elderly patients and those at high risk for surgery.

Percutaneous endovascular treatment of an iatrogenic superior cava vein syndrome during the immediate post-operative period after mitral-aortic valve replacement

Superior vena cava syndrome (SVCS) results from superior vena cava obstruction, causing a decrease in venous return from the head, neck, and upper extremities. Although the most frequent cause is still malignant tumour processes, in recent years an increase has been observed in non-tumour causes, such as thrombosis of intravascular devices or iatrogenic causes during cardiac surgery. A case is presented of SVCS after cardiac surgery treated satisfactorily by an endovascular technique and systemic anticoagulation.

Endovascular Therapy for Central Venous Thrombosis

Central vein thrombosis is defined as thrombosis of the major vessels draining either the upper or lower extremities. It presents most commonly in the upper limb, where it affects the subclavian veins and the superior vena cava; in the lower limb, it affects the common iliac veins and the inferior vena cava. These different anatomical segments pose unique challenges in both acute and chronic settings, and this article will summarize the current best practice treatment options.