Superior Vena Cava Stent Placement Research Articles

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.

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.

Second SVC stent treatment for tumour ingrowth.

Key messageWe herein report a case of lung cancer with recurrent superior vena cava (SVC) syndrome, which was treated with additional stent placement. Our report suggests the possibility that additional SVC stent placement is an option for treatment of tumour ingrowth, even in patients with poor performance status.

Reoperations after the correction of partial abnormal venous return: a clinical case series

Rationale: The surgical procedure for partial abnormal pulmonary venous return (PAPV) implies the formation of a tunnel between the orifices of the right pulmonary veins and the left atrial cavity with the interatrial septum repair. To avoid any obstruction of the tunnel, a direct anastomosis between the superior vena cava (SVC) and the right atrial appendage is placed in a number of cases. However, the reparative procedure is potentially associated with such complications as SVC stenosis and/or pulmonary vein stenosis. Aim: To present our experience of reoperations for stenosis of systemic and pulmonary veins after primary PAPV repair. Materials and methods: From 2014 to 2018, seven patients (boys, 4) with SVC stenosis and/or with stenosis of the right pulmonary veins have been admitted to the FCHMT (Kaliningrad). Their mean bodyweight was 29.1 kg (± 12.5 kg), mean age 9.3 years (± 3.6 years). Three patients had an isolated SVC stenosis. In two patients, there was a combination of SVC stenosis and pulmonary vein obstruction (from stenosis to complete occlusion); in one patient the right pulmonary vein stenosis had been caused by thrombosis. SVC stenosis with subaortal obstruction after the repair of double-outlet right ventricle was diagnosed in one case. In six patients, various procedures for correction of SVC and/or pulmonary vein stenosis were performed. Only in one case the obstruction of systemic veins, confirmed by cardiac catheterization, turned out to be non-significant, making a reoperation unnecessary. Results: There were no deaths in this patient group. Endovascular procedures were performed in two patients. In one case, there was an unsuccessful attempt of transluminal balloon angioplasty for SVC stenosis, with subsequent Warden procedure. In another case, a 16-year old patient with SVC stenosis and high pulmonary hypertension was admitted after two previous surgeries had failed. We used a homograft as SVC prosthesis; however, after one year, a re-stenosis was identified. In this case, a SVC stent placement was successful. Due to sick sinus syndrome at one year after the Warden procedure and the repair of pulmonary veins by a homograft, an implantation of electric cardiac pacemaker was necessary in one patient. Conclusion: The curative repair of partial abnormal venous return is a well-established surgical technique with satisfactory shortand long-term results. A potential complication of the procedure is an obstruction of systemic and pulmonary veins. To prevent such complications during primary defect repair, as well as with reoperations for vein stenosis, the Warden procedure seems effective and highly reproducible technique associated with lower surgical risks.

Antithrombotic Therapy Post Endovascular Stenting for Superior Vena Cava Syndrome.

Superior vena cava syndrome results in obstruction of the superior vena cava and commonly requires intervention. Stents are often used to increase the patency of the vena cava and to prevent reocclusion. The role of antithrombotic therapy and agents to use has been highly debated due to stent location, hematologic complications, and limited clinical evidence available on the topic. This commentary seeks to determine the appropriate choice, if any, for antithrombotic therapy after superior vena cava stent placement. Received date: 13/04/2016 Accepted date: 04/05/2016 Published date: 11/05/2016

Transcatheter treatment of SVC syndrome from histoplasmosis‐related mediastinal fibrosis in a 9‐year old male

We report a case of mediastinal fibrosis secondary to histoplasmosis in a 9-year old male, who presented with superior vena cava syndrome. He was successfully treated by percutaneous superior vena cava stent placement in the outpatient cardiac catheterization laboratory.

Life-threatening Cerebral Edema Caused by Acute Occlusion of a Superior Vena Cava Stent

A71-year-old man with advanced lung cancer developed a life-threatening cerebral edema caused by the acute occlusion of a superior vena cava (SVC) stent and was successfully treated by an additional stent placement. Although stent occlusion is a common early complication, no life-threatening situations have been reported until now. Our experience highlights the fact that acute stent occlusion can potentially lead to the complete venous shutdown of the SVC, resulting in life-threatening cerebral edema, after SVC stent placement. Immediate diagnosis and countermeasures are required.

Stenting for superior vena cava obstruction in pediatric heart transplant recipients

Superior vena cava (SVC) obstruction can be a complication in heart transplant recipients. We reviewed our experience with relief of SVC obstruction using endovascular stents in pediatric heart transplant recipients. Study cohort included pediatric heart transplant recipients, followed at our institution, who required endovascular stent placement for SVC obstruction. Data retrieved retrospectively included cardiac diagnosis, age, and weight at transplant, surgical technique of transplant (bicaval vs. biatrial anastomosis), previous cardiovascular surgeries, presenting symptoms, date of SVC stent placement, and need for reintervention. From March 1990 to June 2006, 5.1% (7/138) pediatric heart transplant recipients who were followed at our institution had SVC obstruction requiring stent placement. Median age and weight at transplant was 9 months and 8.7 kg, respectively. Four patients previously had a cavopulmonary anastomosis. Transplant surgery involved bicaval anastomosis in 6 and biatrial in 1. Of the 7 patients included in the study, 2 were asymptomatic, 2 were symptomatic (1 with chylothorax, 1 with headache), and 3 were identified at the time of transplant surgery. Median time from transplant surgery to SVC stent placement was 2 months (0-14 months). Three patients required reintervention as redilation of SVC stent (n = 1) or additional SVC stent (n = 2). In one patient the stent migrated to the pulmonary artery but was retrieved. SVC obstruction can be an important complication following heart transplantation, especially in infants with previous cavopulmonary anastomosis, undergoing heart transplant using bicaval technique. SVC obstruction can be safely and effectively treated using endovascular stents.

STENTING FOR SUPERIOR VENA CAVA OBSTRUCTION IN PEDIATRIC HEART TRANSPLANT RECIPIENTS.

Purpose Superior vena cava (SVC) obstruction can be a complication of reconstructive surgery done at the time of heart transplantation. Pediatric patients are at a higher risk compared with adults due to their smaller size, growth potential, multiple central line access, and complex native venous anatomy related to congenital heart disease. SVC obstruction can not only make these patients symptomatic but also limit access for obtaining cardiac biopsy. We reviewed our experience with relief of SVC obstruction using endovascular stents in pediatric heart transplant recipients. Methods A retrospective review of medical records of patients ( Results From March 1990 to June 2006, 138 pediatric patients were followed at our institution after heart transplantation. Of these, 7 developed SVC obstruction and formed the study cohort. Median age at transplant was 9 months (2.5-180 months); median weight was 8.7 kg (3.4-76 kg); cardiac diagnosis was heterotaxy syndrome (3), atrioventricular canal defect (1), double-outlet right ventricle (1), tricuspid atresia (1), hypoplastic left heart syndrome (1). Surgical technique at transplant involved cavocaval anastomosis in six and biatrial anastomosis in one. One patient had a SVC stent placed at transplant surgery due to severe obstruction. One patient presented with persistent pleural effusions and facial swelling; others were asymptomatic and diagnosed by echocardiography and/or cardiac catheterization. Median time from transplant surgery to SVC stent placement was 2 months (0-14 months). During a median follow-up of 4 years since transplant, one required redilation of SVC stent and two required an additional SVC stent. There were no complications related to stent placement. Conclusion SVC obstruction can be an important although uncommon complication, especially in infants undergoing heart transplant using cavocaval technique. This obstruction can be safely and effectively relieved using endovascular stents.

Effective dose to the patient undergoing superior vena cava stent.

Metallic stents have been recently introduced for treating superior vena cava (SVC) obstruction. Dose data, in terms of dose-area product (DAP), from 44 patients referred for SVC stent placement on a digital unit have been retrospectively analysed in terms of their fluoroscopic and radiographic components. The mean DAP for the 44 examinations was 42 Gy cm2 and the effective dose was estimated to be 5.8 mSv. The fluoroscopic component was approximately 80%, with a mean screening time for these examinations of 17 min. The mean number of digital exposures was 86.

Superior vena cava stent placement: results with the Wallstent endoprosthesis.

To assess the clinical success and short-term patency of the Wallstent endoprosthesis in the treatment of superior vena cava (SVC) syndrome. Twenty-one 14-mm-diameter endoprostheses were implanted in 15 patients (mean age, 60 years) treated for SVC syndrome due to malignant compression (n = 14) or postirradiation fibrotic stenosis (n = 1) of the SVC. Immediate technical success was achieved in all patients. Two early complications occurred: retroperitoneal hemorrhage due to venous iliac tear and early stent thrombosis. In the 14 patients without early stent occlusion, stent placement resulted in complete relief of SVC syndrome; clinical success was 93%. SVC syndrome did not recur from 1 to 14 months, until the patient died (n = 11) or until the end of the study (n = 3). Helical CT showed a patent stent in five patients, respectively, at 3, 6, 8, 10, and 11 months. SVC stent placement has good clinical results and a high patency rate at short-term follow-up in patients with SVC syndrome.

Superior vena cava obstruction: Clinical syndrome, etiology, and treatment

To 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.Between 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.Technical 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).SVC 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.