[Therapy of venous stenosis using wall stents]

WITHDRAWN: Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus

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Physiologic effect of stent therapy for inferior vena cava obstruction due to malignant liver tumor

PURPOSE

To understand systemic the influence of stent therapy for inferior vena cava (IVC) obstruction due to advanced liver tumor.

METHODS

Seven patients with symptomatic IVC obstruction due to advanced primary (n = 4) or secondary (n = 3) liver tumor were subjected to stent therapy. Enrollment criteria included high IVC pressure over 15 mmHg and the presence of edema and ascites. Z-stents were deployed using coaxial sheath technique via femoral venous puncture. Physiologic and hematobiochemical parameters were analyzed.

RESULTS

All procedures were successful, and the stents remained patent until patient death. Promptly after stent placement, the IVC flow recovered, and the venous blood pressure in the IVC below the obstruction level showed a significant decrease from 20.8 +/- 1.2 mmHg (mean +/- SE) to 10.7 +/- 0.7 mmHg (p < 0.01). Transient mild increase of right atrial pressure was observed in 1 patient. During the following week prominent diuresis was observed in all patients. Mean urine output volume in the 3 days before the stent therapy was 0.81 +/- 0.09 l/day compared with 2.1 +/- 0.2 l/day (p < 0.01) in the 3 days after. The edema and ascites decreased in all patients. The caval pressure change correlated well (r > 0.6) with the urine volume increase, and with the decreased volume of edema and ascites. The urine volume increase correlated well with the decrement of edema, but not with that of ascites. Improvements for various durations in the levels of blood urea nitrogen, serum creatinine, lactate dehydrogenase, fibrinogen, and platelet count were found (p < 0.05). These hematobiochemical changes were well correlated with each other and with the decrement of ascites. Two patients showed a low blood sodium level of 128.5 mEq/l after intensive natriuresis, and one of them died on day 21 with hepatic failure, which was interpreted as maladaptation aggravation. The mean survival time was 94.1 +/- 34.1 days (mean +/- SD), ranging from 21 to 140 days after stent treatment.

CONCLUSION

The stent therapy for IVC obstruction due to malignant liver tumors was followed by a series of physiologic and hematobiochemical consequences, most of them favorable but some possibly unfavorable. Rational interpretations and predictions of sequelae based on physiologic science including cardiology, hepatology, and nephrology would facilitate the best management of stent therapy for malignant IVC obstruction.

Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review

OBJECTIVE

To conduct a systematic review to determine the relative effectiveness of treatments currently employed in the management of superior vena caval obstruction (SVCO).

SEARCH STRATEGY

Electronic searching of the Cochrane Clinical Trials Register, Medline and Embase with identification of further studies from references cited in trials identified by electronic searching.

SELECTION CRITERIA

Both randomized and non-randomized controlled trials in which patients with carcinoma of the bronchus and SVCO had been treated with any combination of steroids, chemotherapy, radiotherapy or insertion of an expandable metal stent.

DATA COLLECTION AND ANALYSIS

There were three randomized and 98 non-randomized studies of which two and 44 respectively met the inclusion criteria.

MAIN RESULTS

Superior vena caval obstruction was present at diagnosis in 10.0% of patients with small cell lung cancer (SCLC) and 1.7% of patients with non-small cell lung cancer (NSCLC). In one small randomized trial in SCLC, the rate of SVCO relapse was not significantly reduced by giving radiotherapy on completion of chemotherapy. In another, in NSCLC, the addition of induction chemotherapy to a course of synchronous chemo-radiotherapy did not provide greater relief of SVCO. In SCLC chemotherapy and/or radiotherapy relieved SVCO in 77%; 17% of those treated had a recurrence of SVCO. In NSCLC, 60% had relief of SVCO following chemotherapy and/or radiotherapy; 19% of those treated had a recurrence of SVCO. Insertion of an SVC stent relieved SVCO in 95%; 11% of those treated had further SVCO but recanalization was possible in the majority resulting in a long-term patency rate of 92%. Morbidity following stent insertion was greater if thrombolytics were administered.

REVIEWERS' CONCLUSIONS

Chemotherapy and radiotherapy are effective in relieving SVCO in a proportion of patients whilst stent insertion may provide relief in a higher proportion and more rapidly. The effectiveness of steroids and the optimal timing of stent insertion (whether at diagnosis or following failure of other modalities) remain uncertain.

Successful stenting of a complex inferior vena cava stenosis using a modified sharp recanulization technique

We describe a case of a 30-year-old male who presented with features of noncirrhotic portal hypertension, who was diagnosed to have inferior vena cava (IVC) obstruction. IVC angiogram and ultrasound study revealed a long-segment (36 mm long), chronic total thrombotic occlusion that was dilated and stented with a satisfactory end result. The unique feature of this case is a modified sharp recanulization technique involving the use of Brokenborough (septal puncture) needle and Mullin dilator to create a track in such a long, chronic total occlusion under simultaneous ultrasound and fluoroscopic guidance.

Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus

BACKGROUND

Superior vena caval obstruction (SVCO) is an uncommon manifestation of carcinoma of the bronchus characterised by neck swelling and distended veins over the chest. In recent years, the majority of patients with small cell lung cancer (SCLC) with SVCO at diagnosis have tended to receive chemotherapy whilst the majority of patients presenting with non-small cell lung cancer (NSCLC) and SVCO have tended to receive radiotherapy. Steroids may also be prescribed. Stenting now provides a further treatment option which may be combined with radiotherapy and chemotherapy or used on its own. The optimal timing of stenting at present is unclear.

OBJECTIVES

To determine the relative effectiveness of treatments currently employed in the management of SVCO.

SEARCH STRATEGY

Electronic searching of Cochrane Clinical Trials register, Medline and Embase. Identification of further studies from references cited in trials identified by electronic searching.

SELECTION CRITERIA

Both randomised and non-randomised controlled trials in which patients with carcinoma of the bronchus and a diagnosis of SVCO had been treated with any combination of the following treatment modalities: steroids, chemotherapy, radiotherapy or insertion of an expandable metal stent.

DATA COLLECTION AND ANALYSIS

There were 3 randomised and 98 non-randomised studies of which 2 and 44 respectively met the inclusion criteria.

MAIN RESULTS

SVCO was present at diagnosis in 10.0% of patients with SCLC and 1.7% of patients with NSCLC. In one randomised trial in SCLC, the rate of SVCO relapse was not significantly reduced by giving radiotherapy on completion of chemotherapy. In the other, in NSCLC, the addition of induction chemotherapy to a course of synchronous chemo-radiotherapy did not increase the rates of relief of SVCO. In SCLC, chemotherapy and/or radiotherapy relieved SVCO in 77%; 17% of those treated had a recurrence of SVCO. In NSCLC, 60% had relief of SVCO following chemotherapy and/or radiotherapy; 19% of those treated had a recurrence of SVCO. Insertion of an SVC stent relieved SVCO in 95%; 11% of those treated had further SVCO but recanalisation was possible in the majority resulting in a long-term patency rate of 92%. Morbidity following stent insertion was greatest if thrombolytics were administered. No study described the effectiveness of steroids in SVCO.

REVIEWER'S CONCLUSIONS

Chemotherapy and radiotherapy are effective in relieving SVCO in a proportion of patients whilst stent insertion appears to provide relief in a higher proportion and more rapidly. The optimal timing of stent insertion (whether at diagnosis or following failure of other modalities) is currently uncertain. The effectiveness of steroids in SVCO remains uncertain.