Malignant Superior Vena Cava Syndrome Research Articles

In-hospital outcomes of patients with lung cancer with and without superior vena cava thrombosis: A nationwide analysis.

e23322 Background: Malignant superior vena cava syndrome (SVCS) is a clinical problem that results from the obstruction of blood flow in the superior vena cava by an underlying malignancy. It may be caused by external compression or internal obstruction due to a thrombus or direct invasion by tumor cells. Though lung malignancy is the most common cause of SVCS, there is a lack of data on in-hospital outcomes in these patients. Methods: We queried the National Inpatient Sample 2018-2020 to identify hospitalizations with lung cancer including both small cell and non small cell lung cancer. Hospitalizations with diagnosis of acute SVC thrombosis were determined by using ICD-10 codes.Demographics and mortality rates were compared between two groups using chi square for categorical variables and t test for continuous variables. Multivariate regression analysis was further performed to study the impact of SVC thrombosis on mortality, LOS and total hospitalization cost. Results: A total of 2011620 hospitalizations with lung cancer were identified. Of these, 2855 (0.0014%) had acute SVC thrombosis. These patients were younger with a mean age of 63 years. African-Americans and Hispanics were in a higher proportion in the cohort of hospitalizations with SVC thrombus as compared to those without. (Table 1). Multivariate regression analysis revealed higher odds of mortality (OR-1.94; C.I: 1.53-2.47; P < 0.001), LOS (OR 1.66; C.I:1.20- 2.31; P < 0.005) and total hospitalization cost (26211.15; C.I:22183.56- 30238.74; P < 0.001) in lung cancer hospitalizations. Conclusions: Our study shows that SVCT, has higher odds of mortality, length of stay and total hospital cost. Though the general recommendation is to continue anticoagulation, sometimes patients may require endovascular stent placement with/without thrombectomy. Though rare, SCVT can be life threatening and requires prompt attention.[Table: see text]

Results of Palliative Stenting in Malignant Superior Vena Cava Syndrome Analyzing Self-Expanding Stainless Steel and Nitinol Venous Bare Metal Stents.

The purpose was to analyze the technical, clinical, and survival outcomes of our patients with malignant superior cava vein syndrome (SVCS) treated with endovascular approach and analyze the efficacy of different stent types used. It is an observational, retrospective, single-center study. From 2006 to 2023, 42 patients (32 male, 10 female, mean age 62 years, age range, 41-87 years) underwent percutaneous stent placement for malignant SVCS. One stainless steel stent (Wallstent) and 2 venous nitinol stent type (Sinus-XL, Venovo) were used. Follow-up mean was 276 days. A total of 53 stents were deployed. Clinical success was 97.6% in less 24 hours. Technical success was achieved in 97.6%. No complications were found except 1 patient died during the procedure due to stent migration and atrial dissociation (2.3%). Overall intraprocedural stent migration rate was 11.9% (18.8% stainless steel stent, 9.6% nitinol stent, p>0.05). Overall survival rates were 87.8%, 41.99%, and 34.12%, and overall primary patency rates were 100%, 93.3%, 91.6% at 1, 6, and 12 months, respectively. Endovascular treatment is a safe and effective therapeutic option for SVCS with high technical and clinical success rates and low complication and recurrence rates. The malignant superior cava vein syndrome is a rare clinical entity treated classically with radiation and chemotherapy with a slower response, or surgical bypass, which is an aggressive surgical technique. Endovascular treatment offers a low-invasive technique with quick clinical resolution and good permeability results. However, further studies are lacking to deal with procedure technical characteristics, stent type used, technical complications, and medium- and long-term patency studies. This study aims to evaluate all these items, analysing self-expanding stainless steel and nitinol venous bare metal stents, and add value to endovascular treatment, confirming the good results of this technique.

Safety and efficacy of large-bore uncovered stents for treating malignant superior vena cava syndrome

PurposeTo investigate the safety and efficacy of large-bore uncovered stents for treating malignant superior vena cava syndrome. MethodsThis retrospective study included 115 patients (89 men, 26 women; mean age 63.2 years; range 21–83 years) who underwent endovascular large-bore (≥18 mm in diameter) uncovered stent placement between August 2015 and July 2022. One patient was lost to follow-up. Therefore, 114 patients were available for follow-up. ResultsStent placement was technically successful in all 115 patients. Minor procedure-related complications occurred in nine (7.8 %) patients. One hundred eight (93.9 %) patients experienced complete or marked symptomatic relief (Kishi score ≤ 2) at a mean of 3 days after procedure. The cumulative stent patency rates were 98.2 %, 95 %, 93.7 %, 91.5 %, 83.5 %, and 83.5 % at 1, 3, 6, 12, 18, and 24 months, respectively. Stent occlusion occurred in ten (8.8 %) of 114 patients at a mean of 215 days (range 1–732 days) due to thrombosis (n = 7) and tumor ingrowth (n = 3). Stent occlusion did not occur in 21 patients who underwent subsequent central venous catheter insertion. The median patient survival time was 159 days (95 % confidence interval 102–216 days). Univariate and multivariate Cox regression analysis revealed adjuvant anticancer treatment (p = 0.001) and tumor response (p < 0.001) as independent predictors of patient survival. ConclusionsEndovascular placement of large-bore uncovered stents was a safe and effective treatment for malignant superior vena cava syndrome. Large-bore stent placement can effectively prevent stent occlusion by tumor ingrowth in most cases, and it can provide a sufficient diameter for subsequent insertion of central venous catheters.

Outcomes in patients managed with endovascular stent for malignant superior vena cava syndrome

BackgroundMalignant Superior Vena Cava Syndrome (SVCS) corresponds to the clinical manifestations due to the restriction of venous return to the right atrium secondary to obstruction of the superior vena cava and/or its main tributaries for a tumor. Endovascular management has proven to be safe, effective and cause a fast symptomatic relief in patients with SVCS. There is limited evidence in factors associated with outcomes in malignant setting for this procedure. Materials and methodsAn analytical retrospective study was conducted and included patients that underwent endovascular management for malignant SVCS at the National Cancer Institute of Colombia between May 2016 and May 2021. Clinical and technical variables were analyzed to found associations with outcomes in these patients. Results54 patients were analyzed. Successful procedure rate was 94.4 %. At 10 months, the OS of the entire cohort of patients was 25 %. Patients with breast or lung cancer (P = 0.031), unsuccessful procedure (P = 0.011), and also with short time of symptoms to the date of the endovascular procedure (P = 0.027) had worse OS. Multivariate analysis showed that lung cancer [HR = 2.55, 95%IC:(1.21–5.36)] and left internal jugular vein or left Innominate vein distal stent attachment [HR = 3.27, 95%IC:(1.31–8.15)] were independent factors for worst OS. ConclusionsBased in the high success rate of the endovascular management and the better outcome in patients with early and successful procedure, this procedure should be considered as part of the multimodal treatment in patients with SVCS independent of the clinical scenario and the oncological diagnosis.

Clinical outcomes of intra-arterial chemotherapy combined with iodine-125 seed brachytherapy in the treatment of malignant superior vena cava syndrome caused by small cell lung cancer

PurposeCurrently there is a lack of effective treatment strategies for malignant superior vena cava syndrome (SVCS). We aim to investigate the therapeutic effect of intra-arterial chemotherapy (IAC) combined with the Single Needle Cone Puncture method for the 125I brachytherapy (SNCP-125I) in treating SVCS caused by stage III/IV Small Cell Lung Cancer (SCLC). Materials and methodsSixty-two patients with SCLC who developed SVCS from January 2014 to October 2020 were investigated in this study. Out of these 62 patients, 32 underwent IAC combined with SNCP-125I (Group A) and 30 patients received IAC treatment only (Group B). Clinical symptom remission, response rate, disease control rate, and overall survival of these two groups of patients were analyzed and compared. ResultsThe remission rate of symptoms including dyspnea, edema, dysphagia, pectoralgia, and cough of malignant SVCS in Group A was significantly higher than that in Group B (70.5 and 50.53%, P=0.0004, respectively). The disease control rates (DCR, PR+CR+SD) of Group A and B were 87.5 and 66.7%, respectively (P=0.049). Response rates (RR, PR+CR) of Group A and Group B were 71.9 and 40% (P=0.011). The median overall survival (OS) of Group A was significantly longer than that in Group B which was 18 months compared to 11.75 months (P=0.0360). ConclusionsIAC treatment effectively treated malignant SVCS in advanced SCLC patients. IAC combined with SNCP-125I in the treatment of malignant SVCS caused by SCLC showed improved clinical outcomes including symptom remission and local tumor control rates than IAC treatment only in treating SCLC-induced malignant SVCS.

Malignant Superior Vena Cava Syndrome: State of the Art.

Superior vena cava syndrome (SVCS) is a clinical entity characterized by signs and symptoms arising from the obstruction or occlusion of the thin-walled superior vena cava (SVC) and can result in significant morbidity and mortality. Despite the rise of benign cases of SVCS, as a thrombotic complication of intravascular devices, it is most commonly seen secondary to malignancy as a consequence of thrombosis, direct invasion of tumor cells inside the vessel, or external compression. SVCS can be the initial presentation of a previously undiagnosed tumor in up to 60% of cases. Lung cancer and non-Hodgkin lymphoma (NHL) are responsible for up to 85%-90% of malignancy-related SVCS, while metastatic cancers account for approximately 10%. Herein, we review the pathophysiology, etiology, clinical presentation, diagnosis, and management of malignancy-related SVCS.

Safety and Efficacy of Stent Graft Implantation for Malignant Superior Vena Cava Syndrome.

Patients with malignant superior vena cava syndrome (SVCS) usually require urgent treatments due to a high potential risk of early mortality. Stent implantation can rapidly improve the symptoms of SVCS, which may be beneficial to subsequent anti-tumor therapy. The aim of the study was to evaluate the clinical outcomes of stent graft implantation for the treatment of superior vena cava (SVC) obstruction caused by non-small cell lung carcinoma (NSCLC) with acute post-stenting occlusion. Between October 2014 and December 2019, 16 patients were selected for stent graft implantation. Technical success and clinical efficacy were assessed. Stent patency and patient survival rates, as well as the complications were analyzed. There were 17 stent grafts implanted in 16 patients. The technical success was 100%. The residual stenosis after initial implantation was 64.0 ± 9.0%. The stent expanded to an optimal size in 5.5 ± 2.2 days after the initial deployment. Migration occurred when deploying of the stent graft in one patient; this stent graft was successfully stabilized by a second one. No other complications related to the procedure were found except one migration. At 1, 3, 6, 9 and 12 months, the cumulative survival rates were 100%, 75%, 56%, 19% and 0%, respectively. The mean OS was 173 days. The median survival was 166 days. Stent graft can be safely used in patients with SVC obstruction with a good long-term patency rate.

Thrombosis and Anticoagulation in Malignant Superior Vena Cava Syndrome

▪Background:Superior Vena Cava (SVC) Syndrome (SVCS), defined by obstruction of blood flow through the SVC, is commonly caused by a mediastinal tumor (i.e. malignant SVCS, m-SVCS). Little is known regarding co-existing SVC thrombosis at diagnosis in this high risk setting. Anticoagulation (AC) is often utilized even in the absence of thrombosis or stents, but evidence is lacking.Aims:1) To determine factors associated with thrombosis and AC at m-SVCS diagnosis; 2) To evaluate the effect of baseline AC and SVC thrombosis on outcomes.Methods:The electronic records of 2 academic medical centers in Israel were screened for diagnostic codes compatible with SVCS and malignancy between 2007 and 2015. Patients were included if they had active cancer and m-SVCS reported in chest computerized tomography (CT) with intravenous (IV) contrast medium. Records were followed from m-SVCS diagnosis for 6 months.Baseline patient, cancer and m-SVCS-related characteristics were collected. AC use and endovascular SVC stent placement were recorded throughout the study. Accessible diagnostic and follow-up IV contrast CTs were reviewed by two radiologists to confirm m-SVCS diagnosis and evaluate thrombosis. The primary endpoint was death from any cause. Secondary endpoints included new/recurrent SVC thrombosis. Baseline variables that had a statistically significant association with baseline thrombosis or death on univariate analysis were entered into a General Linear Model and multivariable cox regression model, respectively, for multivariable analysis. Significance was set at p < 0.05.Results:The cohort included the 183 patients, 70% (129) of whom had a reviewable baseline CT. Baseline characteristics are shown in Table 1. Briefly, 65% (119/183) had newly diagnosed cancer of any histology, 22% (40/183) had hematological malignancy (mainly aggressive lymphoma), and 16% (29/183) had no symptoms attributable to m-SVCS (i.e. clinical grade 0). Thrombosis of the SVC or tributaries at diagnosis was seen in 24% (30/127). Baseline AC (within 21 days of m-SVCS diagnosis) was used in 51% of patients for a median duration of 68 days [range: 14-179]. Thirty percent of thrombotic cases received no AC, while 52% of non-thrombotic cases received AC at varying doses. Patients receiving baseline AC were more likely to have had a SVC stent placed at baseline, and had higher grade venous occlusion and a trend to more thrombosis of SVC and tributaries (univariate analysis; Table 1). On multivariate analysis, only symptomatic m-SVCS (P<0.01) and increasing Khorana score (p<0.05) were associated with baseline thrombosis (univariate analysis shown in Table 1).Over a median FU of 44 [IQR 22-93] days, 49% (90/182) of patients died. A follow up CT was performed in 61/129 (47%) patients at a median of 138 days [IQR 71-182] from diagnosis, 30% (18) of whom died. New thrombosis of SVC and tributaries was identified in 10/61 (16%) at a median of 74 days [IQR: 53-150]. Patients with baseline AC had thrombosis on follow-up CT in 21% of cases (8/40) compared to 10% (2/20) in those without baseline AC (p=0.471). Among the 68/129 without a follow up CT, 45 (66%) died over a median follow up of 72 days (IQR 23-182).In time dependent cox analysis, baseline AC (compared to none) was not associated with risk of death (HR 0.85; 95% CI 0.55-1.29). In multiple regression analysis of baseline variables, increasing age (HR 1.04, 95% CI 1.02-1.06), malignancy stage IV (HR 4.57, 95% CI 2.29-9.13) and refractory cancer (HR 1.95, 95% CI 1.17-3.25) were associated with death.Conclusion:Thrombosis of SVC and tributaries is a common complication of m-SVCS, and is associated with symptomatic presentation and a high Khorana score. Prognosis in m-SVCS is dismal and appears to be determined by the prognosis of the underlying cancer and responsiveness to prior anticancer therapy and not by the presence of thrombosis at diagnosis. The high early death rate, low numbers of thrombotic events and confounding by AC indication, preclude ruling out a role for AC in selected cases. We propose that therapeutic dose AC in thrombotic m-SVCS and prophylactic AC in non-thrombotic m-SVCS be evaluated prospectively in newly diagnosed patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Clinical analysis of 48 cases of malignant superior vena cava syndrome

BackgroundThe aim of our study was to observe and compare the curative effect of radiotherapy, chemotherapy, and combined radiotherapy and chemotherapy, as well as comprehensive treatment on superior vena cava syndrome (SVCS) caused by malignant etiology.MethodsA total of 48 patients with malignant SVCS admitted to our hospital from 2015 to 2020 were selected in this study. According to the different treatment methods, they were divided into radiotherapy group (group 1, 10 cases), chemotherapy group (group 2, 8 cases), combined radiotherapy and chemotherapy group (group 3, 22 cases), and comprehensive treatment group (group 4, 8 cases).ResultsThere were no significant differences in efficacy and side effects among the four groups (all P > 0.05). Group 4 (median survival time of 36 months) could provide longer survival time than groups 1, 2, and 3 (median survival time of 10 months, 13.5 months, and 12 months, respectively).ConclusionsFor patients with severe symptoms or good prognosis, comprehensive treatment could be selected to improve the quality of life and prolong the survival period; for patients with mild symptoms, radiotherapy, chemotherapy, or combined radiotherapy and chemotherapy could also reduce the symptoms of SVCS and treat tumor lesions.

Erosion of Superior Vena Caval Stent into Trachea, An Unusual Cause of Hemoptysis.

Erosion of Superior Vena Caval Stent into Trachea, An Unusual Cause of Hemoptysis.

Endovascular Treatment of Malignant Superior Vena Cava Syndrome through Upper-Limb Access: A Comparison between Venous-Dedicated and Conventional Stents

PurposeTo retrospectively evaluate the technical and clinical outcomes of superior vena cava (SVC) stent placement through upper-limb venous access in malignant SVC syndrome (SVCS) and compare the efficacy of different nitinol stent types. Materials and MethodsBetween 2006 and 2018, 156 patients (132 male; mean age, 62 y; age range, 33–81 y) underwent SVC stent placement for malignant obstructions through upper-limb venous access with 1 of 3 types of nitinol stent: 1 venous-dedicated (Sinus-XL stent) and 2 non–venous-dedicated (E-Luminexx Vascular Stent and Protégé GPS). Cases of common femoral vein access or non-nitinol stents were excluded from further analysis. The mean duration of follow-up was 8 mo. ResultsTechnical success was achieved in 99.3% of cases. One patient died during the procedure as a result of cardiac tamponade. Balloon predilation was performed in 10 patients and postdilation in 126. Mean procedural time was 34.4 min (range, 18–80 min). Overall survival rates were 92.3%, 57.3%, and 26.8%, and overall primary patency rates were 94.5%, 84.8% and 79.6%, at 1, 6, and 12 mo, respectively. There were no statistically significant differences in primary patency rates between venous- and non–venous-dedicated stents or among different Stanford SVCS grading groups (P > .05). ConclusionsSVC stent placement through an upper-limb approach is a safe, fast, and effective technique. There is no evident benefit of venous-dedicated vs non–venous-dedicated stents in the treatment of malignant SVCS.

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.

Computed Tomography Findings Associated With 30-Day Mortality in Patients With Malignant Superior Vena Cava Syndrome.

The objective of this study was to identify radiological and clinical factors associated with early mortality in malignant superior vena cava syndrome (SVCS). Chest computed tomography studies of 127 patients with malignancy-associated SVCS were retrospectively reviewed. Involvement of SVC and tributaries, pleural and pericardial effusions, pulmonary artery involvement, and ancillary findings were documented. Univariate and multivariate models determined associations between radiological and clinical variables, and 30-day mortality. Thirty-day mortality rate was 16.5% (n = 21). Factors associated with 30-day mortality on univariate analysis included age, cancer stage, SVCS clinical severity, left jugular vein obstruction, number of involved veins, pulmonary arteries involvement, and presence of pleural effusions. Age, SVCS clinical severity, number of veins involved, and pleural effusions were positively associated with 30-day mortality on multivariate analysis. Selected clinical and radiological variables are associated with early death in malignant SVCS. These factors may identify a subgroup of patients who may benefit from treatment escalation.

SQUAMOUS CELL CARCINOMA PRESENTING WITH OBSTRUCTION OF THE SUPERIOR VENA CAVA AND CENTRAL AIRWAYS

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: One mechanism by which cancer causes morbidity/mortality is by mass effect with distortion, compression, or occlusion of nearby anatomical structures. Within the chest, tumors can exert these effects on the airways and vascular structures. This case illustrates the need for urgent intervention in a patient presenting with severe compression of multiple intrathoracic structures. CASE PRESENTATION: A 54 year-old man with chronic tobacco use and limited exposure to healthcare presented to the hospital with gradually progressive shortness of breath over several months, followed by facial swelling, severe wheezing, and recurrent syncope over the past few days. Exam was remarkable for facial flushing and diffuse inspiratory/expiratory wheezing. Laryngoscopy was performed, which did not suggest critical airway edema. Computed tomography (CT) of the chest demonstrated a large right-sided suprahilar mass, with severe compression of the superior vena cava (SVC) and right mainstem bronchus (RMB) and bronchus intermedius, narrowing of the right pulmonary artery and vein, and complete collapse of the right upper lobe. The patient underwent urgent placement of an 11x59mm balloon-expandable covered stent within the SVC, after which the patient reported improvement in facial swelling but minimal improvement in dyspnea. Next, he underwent bronchoscopy, which demonstrated significant extrinsic compression within the right mainstem bronchus; transbronchial needle aspirates of lymph nodes from Stations 4R and 7 were obtained, from which pathology results were consistent with squamous cell carcinoma (SCC). Because of the degree of bronchial compression, and the need for chemotherapy and radiation therapy which could temporarily cause tumoral inflammation and worsen compression/collapse of the right lung, bronchoscopy was repeated, and this time a 12x40mm self-expandable partially-covered stent was placed within the right mainstem bronchus. After this, the patient reported significant improvement in dyspnea, and was discharged to home in stable condition. DISCUSSION: This case describes pulmonary SCC presenting with symptoms of acute SVC syndrome and central airway compression. Lung cancer associated with either of these conditions has dramatically increased morbidity/mortality. In malignant SVC syndrome, stent placement has been shown to reduce SVC pressure and improve symptoms; there is moderate risk of stent re-obstruction. Though not free of risks, endobronchial stent placement can prevent the impending occlusion of a central airway, when surgical or endobronchial resection/debulking is not possible. In recent years, there have been numerous advances in the technology and variety of endobronchial stents for multiple indications. CONCLUSIONS: Malignant extrinsic compression of the SVC and central airways is associated with high morbidity/mortality and can be managed urgently and safely with stent placement. Reference #1: Avasarala SK, Freitag L, & Mehta AC. Metallic endobronchial stents: A contemporary resurrection [published online ahead of print December 11, 2018]. CHEST. doi:10.101/j.chest.2018.12.001. Reference #2: Niu S, Xu YS, Cheng L, & Cao C. Stent insertion for malignant superior vena cava syndrome: Effectiveness and long-term survival. Vascular and Interventional Radiology 2017, 122: 633-638. Reference #3: Mudambi L, Miller R, & Eapen GA. Malignant central airway obstruction. Journal of Thoracic Disease 2017, 9(10): 1087-1110. DISCLOSURES: No relevant relationships by Gabriel Ryan, source=Web Response

Thrombosis, anticoagulation and outcomes in malignant superior vena cava syndrome.

Anticoagulation is often used in superior vena cava syndrome (SVCS) associated with cancer (i.e malignant SVCS), even without thrombosis, but its effect on outcomes has not been reported. We aimed to determine factors and outcomes associated with thrombosis and anticoagulation in malignant SVCS. Patients with malignant SVCS diagnosed on computerized tomography (CT) were retrospectively included, indexed at diagnosis and followed for 6 months using medical records. The cohort included 183 patients with malignant SVCS of which 153 (84%) were symptomatic. Thirty of the 127 patients (24%) with a reviewable baseline CT had thrombosis of the SVC or tributaries at diagnosis. Patients with baseline thrombosis more often had symptomatic SVCS (p < 0.01). 70% (21/30) of patients with thrombosis and 52% (49/97) of those without thrombosis at baseline received anticoagulation, most often at therapeutic doses. Thrombosis occurred in 5/39 patients with anticoagulation (13%) compared to 2/18 (11%) of those without, during follow-up (p = 0.85). Anticoagulation was associated with a reduction in risk of SVC stent placement during follow-up that did not reach statistical significance (HR 0.47, 95% CI 0.2-1.13, p = 0.09). Major bleeding occurred in 7 (4%) patients, six of whom received anticoagulation (four therapeutic and two intermediate dose). Neither thrombosis nor anticoagulation affected survival. Anticoagulation is commonly used as primary prevention but its benefit remains to be proven. The role of reduced-dose anticoagulation in non-thrombotic malignant SVCS should be prospectively assessed.

Abstract No. 636 A large-bore uncovered metallic stent for the treatment of malignant superior vena cava syndrome

To investigate the safety and efficacy of large-bore uncovered metallic stent placement in patients with malignant superior vena cava (SVC) syndrome. Between August 2015 and December 2016, 27 consecutive patients (24 men and 3 women; mean age, 64.3 years; range, 52-80 years) with malignant SVC syndrome were retrospectively reviewed. All patients were treated with a large-bore uncovered metallic stent (20-30 mm in diameter). The size of stent was chosen based on the diameter of 15-25% larger than the SVC. The mean diameter of SVC and brachiocephalic vein (BCV) were 18.3 mm and 14 mm, respectively. Stent placement was technically successful in all 27 patients. The mean diameter of the stent was 24 mm. Any overstretching nor overdistension of SVC and BCV was not observed. There were no major complications. The pressure gradient, which was 18.9 ± 8.0 mm Hg before stent placement, dropped significantly to 4.3 ± 3.0 mm Hg after stent placement (p<0.001). Of the 25 patients symptomatic prior to stent placement, 23 (92%) experienced complete symptomatic relief 1-6 days after stent placement. The median patient survival and stent patency time were 116 days 116 days (95% confidence interval [CI], 80-150 days) and 116 days (95% CI, 77-155 days), respectively. Three (11%) of the 27 patients presented with stent dysfunction due to tumor ingrowth (n = 1) and intrastent thrombosis (n = 2). Large-bore uncovered metallic stent placement appeared to be a safe and effective method for treating malignant SVC syndrome.

Endovascular stent-based revascularization of malignant superior vena cava syndrome with concomitant implantation of a port device using a dual venous approach.

The aim of this paper is to evaluate the safety and efficacy of endovascular revascularization of malignant superior vena cava syndrome (SVCS) and simultaneous implantation of a totally implantable venous access port (TIVAP) using a dual venous approach. Retrospectively, 31 patients (mean age 67 ± 8years) with malignant CVO who had undergone revascularization by implantation of a self-expanding stent into the superior vena cava (SVC) (Sinus XL®, OptiMed, Germany; n = 11 [Group1] and Protégé ™ EverFlex, Covidien, Ireland; n = 20 [Group 2]) via a transfemoral access were identified. Simultaneously, percutaneous access via a subclavian vein was used to (a) probe the lesion from above, (b) facilitate a through-and-through maneuver, and (c) implant a TIVAP. Primary endpoints with regard to the SVC syndrome were technical (residual stenosis < 30%) and clinical (relief of symptoms) success; with regard to TIVAP implantation technical success was defined as positioning of the functional catheter within the SVC. Secondary endpoints were complications as well as stent and TIVAP patency. Technical and clinical success rate were 100% for revascularization of the SVS and 100% for implantation of the TIVAP. One access site hematoma (minor complication, day 2) and one port-catheter-associated sepsis (major complication, day 18) were identified. Mean catheter days were 313 ± 370days. Mean imaging follow-up was 184 ± 172days. Estimated patency rates at 3, 6, and 12months were 100% in Group 1 and 84, 84, and 56% in Group 2 (p = 0.338). Stent-based revascularization of malignant SVCS with concomitant implantation of a port device using a dual venous approach appears to be safe and effective.

Stent insertion for malignant superior vena cava syndrome: effectiveness and long-term outcome.

To determine the clinical effectiveness and long-term outcome of stent insertion for malignant superior vena cava (SVC) syndrome. From June 2010 to April 2016, 47 patients with malignant SVC syndrome were treated with stent insertion in our center. Data regarding the technical success, clinical success, and long-term outcome were collected and analyzed retrospectively. SVC stent insertion was successfully performed in all patients. A total of 65 stents were used. No procedure-related complication occurred in these patients. The mean SVC pressure gradient decreased from 17.8mmHg before stent insertion to 7.6mmHg after stent insertion (P<0.001). Clinical success was 100%. During a mean follow-up period of 6months (range 10days-13months), 25 patients underwent subsequent anti-cancer treatment. Six patients (12.8%) experienced re-obstruction of stent 1 to 189days (median 76days) after stent insertion. All patients died during the follow-up. The median stent patency time and survival were 339 and 167days, respectively. The cumulative 3-, 6-, and 12-month stent patency rates were 93.4, 87.4, and 81.2%, respectively. The cumulative 3-, 6-, and 12-month survival rates were 83, 38.3, and 2.1%, respectively. The independent predictors of prolonging survival after stent insertion were lower tumor stage (P=0.018) and subsequent anti-cancer treatment after stent insertion (P=0.009). Stent insertion is a simple, safe, and effective method for patients with malignant SVC syndrome. Subsequent anti-cancer treatment after stent insertion may increase the survival.

A Case of Malignant Superior Vena Cava Syndrome Presenting as Syncope

SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Superior Vena Cava Syndrome (SVCS) is a constellation of clinical symptoms and signs caused by either extrinsic compression or SVC thrombosis. Lung Cancer is the most common cause of SVCS. We present an uncommon case of malignant SVCS presenting with syncope. CASE PRESENTATION: A 55-year-old male presented to the emergency department after passing out in his niece’s parked car. He had lightheadedness and blurred vision before the witnessed, one minute, syncopal episode. He denied any previous history of syncope, heart disease or seizure. He endorsed having progressive neck pain and swelling over the past six months, a twenty-two pounds weight loss over the past year and a forty year pack history of tobacco smoking. Physical examination revealed normal vital signs except for heart rate of 105 bpm. Multiple solid, non-mobile masses were noted on the neck and the chest wall (Figure 1). Distended superficial veins were observed on the diffusely swollen right upper extremity. Significant clubbing was noted in all extremities. Routine syncope workup was unremarkable. CT scan of the neck and chest with intravenous contrast showed the presence of a speculated nodule in the right upper lobe, a large right neck mass, evidence of venous collaterals and soft tissue edema, and extensive upper mediastinal lymphadenopathy significantly narrowing the SVC (Figure 2). Surgical incisional biopsy of a chest wall mass was performed. Histology and immunohistochemistry studies (Figure 2) along with the clinical and radiographic findings confirmed the diagnosis of malignant SVCS secondary to stage IV (T4 N3 M1) poorly differentiated adenocarcinoma of lung origin. Imaging of the brain revealed no evidence of metastases. The patient was hemodynamically stable and with no significant cardiorespiratory compromise. Combined palliative treatment with radiation and chemotherapy was elected. Two years later, the patient continues to maintain good functional capacity. DISCUSSION: This is a case of malignant SVCS presenting uncommonly as syncope. Proper diagnosis, grading, and staging of malignant SVCS are key to its management. Worrisome signs like laryngeal or cerebral edema might warrant an emergent placement of an endovascular stent. Our patient’s SVCS was secondary to stage IV lung adenocarcinoma and was severe based on proposed grading system by Yu et al. Patient has responded well to palliative radiation and chemotherapy. CONCLUSIONS: Accurate diagnosis and staging of SVCS are necessary and help determine the modality and goal of therapy. Reference #1: Wilson, L. D. (2007, 05). Superior Vena Cava Syndrome with Malignant Causes. NEJM, 356(18), 1862-1869. Reference #2: Yu, J. B. (2008, 08). Superior Vena Cava Syndrome—A Proposed Classification System and Algorithm for Management. Journal of Thoracic Oncology, 3(8), 811-814. DISCLOSURE: The following authors have nothing to disclose: Mahrous Abo Hassan, Yahya Kurdi, Xiaoyi Yu, Eric Speakman, Rupesh Raina, Harish Kakarala, Osei-Tutu Owusu No Product/Research Disclosure Information

Stenting in malignant superior vena cava syndrome review advances: in interventional radiology

Superior vena cava (SVC) syndrome is a clinical syndrome which is caused by obstruction or compression of SVC and characterized by congestion and edema of upper body, upper extremities, and face, dilatation of neck, arm, and chest wall veins, respiratory distress, and cyanosis and the patients may experience cough, dyspnoea, haemoptysis, dysphagia, chest pain, headache, visual disturbance, convulsions and coma [1,2]. SVC syndrome may be caused by indwelling catheters, pacemaker wires or fibrosing mediastinitis [3-5] but 90 – 95% of the cases are caused by lung or mediastinal malignant tumors [6]. In these cases tIndication andhe aim of endovascular stent implantation is palliative and to alleviate the patients’ symptoms. It has been used in stenosis and obstruction of SVC for more than two decades [7,8]. Stent has become widely accepted in the management of malignant SVC obstruction and is now an accepted therapy as treatment of malignant SVC obstruction especially in advanced lung cancer and mediastinal tumours. Stenting in malignant SVC obstruction is increasingly been performed as it offers rapid relief of symptoms and gives the patients a better quality of life during their limited life expectancies due to the malignant disease itself.