Superior Vena Cava Rupture and Cardiac Tamponade Complicating the Endovascular Treatment of Malignant Superior Vena Cava Syndrome: A Case Report and Literature Review

Superior Vena Cava Syndrome from Pacemaker Leads in an Elderly Woman

Superior vena cava (SVC) syndrome is a constellation of clinical signs and symptoms secondary to obstruction of the SVC. The most common etiology is malignancy. However, the incidence of device-related SVC syndrome is increasing. The current management for device-related SVC syndrome includes open surgical intervention, endovascular repair, or systemic anticoagulation. We present a case of a 95-year-old female who developed SVC syndrome due to thrombosis secondary to pacemaker leads. She was treated conservatively due to her frailty and comorbid conditions. We discuss the evolving etiology of SVC syndrome, the most common presenting signs and symptoms, and a variety of potential treatments for non-malignant SVC syndrome. We also provide an example of when conservative management for chronic device-related SVC syndrome is appropriate.

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.

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.

Superior vena cava syndrome

The superior vena cava syndrome (SVCS) is caused by compression, invasion, and/or thrombosis of the superior vena cava and/or the brachiocephalic veins. Benign SVCS is separated from malignant SVCS. SVCS comprises a broad clinical spectrum reaching from asymptomatic cases to rare life-threatening emergencies with upper airway obstruction and increased intracranial pressure. Symptoms are correlated to the acuity and extent of the venous obstruction and inversely correlated to the development of the venous collateral circuits. Imaging is necessary to determine the exact underlying cause and to guide further interventions. Interventional therapy has widely changed the therapeutic approach in symptomatic patients. This article provides an overview over this complex syndrome and focuses on interventional therapeutic methods and results.

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.

Delayed pericardial tamponade following central venous recanalization

A patient with central venous occlusion at the junction of the superior vena cava and right atrium underwent endovascular revascularization. The leakage of contrast agents was detected during sharp recanalization that was then managed with covered stent deployment. The initial symptom of facial swelling disappeared and the vital signs were stable after treatment. Regrettably, the patient suffered from the clinical features of cardiac tamponade on the third day post-treatment, which was confirmed by computed tomography. Finally, a pericardial effusion was drained, leading to dramatic improvement in the cardiovascular status of the patient.

Cardiac tamponade after superior vena cava stenting

Superior vena cava (SVC) syndrome results from the blockage of venous blood flow through the SVC, which is caused by either internal obstruction (eg, thrombus) or external compression (eg, thoracic malignancy and infection).1 While thrombus-related SVC syndrome is rising in prevalence, malignancy still accounts for the majority of cases.1 Regardless of cause, SVC syndrome is characterised by facial swelling and plethora, headache and dyspnoea.2 Although venous stenting has become standard of care for treatment of acute SVC syndrome, stent placement presents multiple risks including SVC rupture and cardiac tamponade. In these cases, a high index of suspicion and prompt action are required to avoid an often fatal outcome. Here, we present the case of a patient with cardiac tamponade and subsequent cardiac arrest after SVC stent placement.

Phrenic nerve palsy as a complication of superior vena caval stenting

Superior vena cava obstruction typically results from either primary pulmonary malignancies, lymphoma, or fibrosis related to central catheters. Endovascular stenting of superior vena caval obstruction is a common first approach, due to the rapid clinical improvement typically seen. The commonest complications are recurrence of obstruction and stent migration. We present herein the case of a phrenic nerve palsy secondary to endovascular stenting in a patient with superior vena cava obstruction due to primary small cell lung cancer.

Is Long-Term Anticoagulation Required after Stent Placement for Benign Superior Vena Cava Syndrome?

PURPOSE

To identify whether symptom relief and stent patency vary with use of long-term anticoagulation after stent placement for benign superior vena cava (SVC) syndrome.

MATERIALS AND METHODS

Patients with benign SVC syndrome treated with stent placement between January 1999 and July 2017 were retrospectively identified (n = 58). Average age was 49 years (range, 24-80 y); 34 (58%) were women, and 24 (42%) were men. Average follow-up was 2.4 years (range, 0.1-11.1 y, SD 2.6). Of cases, 37 (64%) were due to a long-term line/pacemaker, and 21 (36%) were due to fibrosing mediastinitis. After stent placement, 36 (62%) patients were placed on long-term anticoagulation, and 22 (38%) were not placed on anticoagulation. Percent stenosis was evaluated on follow-up imaging by dividing smallest diameter of the stent by a normal nonstenotic segment of the stent and multiplying by 100.

RESULTS

Technical success was achieved in all cases. There was no significant difference in number of patients who reported a return of symptoms characteristic of benign SVC syndrome between the anticoagulated (16 of 36; 44.4%) and nonanticoagulated (11 of 22; 50%) groups (P = .68). There was no significant difference in the mean percent stenosis between the anticoagulated (40.4% ± 34.7% [range, 0-100%]) and nonanticoagulated (32.1% ± 29.2% [range, 1.7%-100%]) groups (P = .36). No significant difference was found in the time (days) between date of procedure and date of return of symptoms (anticoagulated, 735.9 d ± 1,003.1 [range, 23-3,851 d]; nonanticoagulated, 478 d ± 826.6 [range, 28-2,922 d]) (P = .49). There was no difference in primary patency between groups (P = .59). Finally, 1 patient (2.8%) in the anticoagulated group required surgical intervention, whereas none in the nonanticoagulated group required surgical intervention.

CONCLUSIONS

No significant difference was observed in clinical and treatment outcomes in patients who did and did not receive anticoagulation after stent placement for benign SVC syndrome. Management of benign SVC syndrome after stent placement may not require anticoagulation if confirmed by additional studies.

Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond

Venous obstruction in the cancer population can result in substantial morbidity and, in extreme cases, mortality. While venous obstruction can be caused by both benign and malignant etiologies in this population, the management of malignant venous obstruction as a palliative measure can be somewhat nuanced with respect to nonprocedural and procedural management, both with respect to treatment of the underlying malignancy as well as treatment of venous hypertension, which may be associated with venous thrombosis. Symptom severity, primary malignancy, functional status, and prognosis are all fundamental to the patient workup and dictate both the timing and extent of endovascular intervention. The morbidity and mortality associated with malignant obstructions of central venous structures, specifically the superior vena cava and inferior vena cava, can be significantly improved with endovascular management in appropriately selected patients. Thus, the pertinent literature regarding the clinical presentation, workup, and endovascular management of malignant central venous obstruction syndromes, with directed attention to superior vena cava syndrome and inferior vena cava syndrome, will be reviewed in this article.