Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 93-95

Upper limb venous approach for stenting superior vena cava syndrome: Two interesting cases and review of literature


1 Department of Cardiology, Apex Heart Institute, Ahmedabad, Gujarat, India
2 Department of Cardiology, The Wright Centre for Graduate Medical Education, Scranton, PA, USA

Date of Submission30-Mar-2019
Date of Decision28-Apr-2020
Date of Acceptance03-Jun-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Sunil Nichaldas Gurmukhani
Department of Cardiology, Apex Heart Institute, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_31_20

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  Abstract 


In superior vena cava syndrome, relieving the obstruction by stenting is the treatment of choice to alleviate the symptoms. We present cases of two patients with superior vena cava obstruction who underwent successful revascularization with the placement of a self-expanding metallic stent using the upper limb venous approach.

Keywords: Revascularization, stenting, superior vena cava syndrome, upper limb venous approach


How to cite this article:
Gurmukhani SN, Shah S, Pancholy S, Patel T. Upper limb venous approach for stenting superior vena cava syndrome: Two interesting cases and review of literature. Indian J Vasc Endovasc Surg 2021;8:93-5

How to cite this URL:
Gurmukhani SN, Shah S, Pancholy S, Patel T. Upper limb venous approach for stenting superior vena cava syndrome: Two interesting cases and review of literature. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Mar 1];8:93-5. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/93/309708




  Introduction Top


Superior vena cava syndrome (SVCS) was first documented by William Hunter in 1757, in a patient with syphilitic aortic aneurysm.[1] SVCS is associated with interruption of normal venous blood flow from the head, upper extremities, and thorax to the right atrium (RA). The presentation consists of clinical features including dyspnea, cyanosis, facial edema, thoracobrachial edema, vision disturbances, orthopnea, stridor, nausea, headache, and syncope.[2]

SVCS is usually caused by the extraluminal compression by the enlarged paratracheal lymph nodes of malignancy, inflammatory processes, thymoma, and aortic aneurysms.[3] It is also associated with thrombus formation due to hypercoagulable conditions and the increasing use of central venous catheters and intracardiac devices.[4] Malignancy accounts for >90% cases of SVCS; however, in recent years, there has been a rise of cases associated with intravascular devices such as catheters and pacemakers.[5] Up to 75% of the benign causes of superior vena cava (SVC) obstruction are associated with indwelling catheters.[4],[6]

The assessment of a patient with possible SVCS should be prompt and focus on the presence or absence of findings that suggest dangerously elevated upper venous pressures in need of urgent or emergent intervention. Treatment for SVCS includes treating the underlying etiology as well as using other modalities such as endovascular stenting in the SVC (with or without thrombolysis or anticoagulation), steroid treatment, oral or intravenous chemotherapy, megavoltage external beam radiation therapy, and sometimes, a combination of these treatments.[7] Since the first case of stenting of SVCS in 1986, endovascular treatment has been shown to be an effective therapy, offering resolution and long-term relief of symptoms.[8]

We describe two patients with SVCS with an underlying malignant etiology who underwent successful percutaneous stenting of critical SVC obstruction through the upper limb venous approach.


  Case Reports Top


Case I

A 75-year-old female presented to us with a history of facial edema, periorbital edema, and dyspnea which began 2 months ago. On presentation, the patient was in moderate respiratory distress. Her physical examination was remarkable for facial plethora and marked symmetric edema of her head, neck, and arms. This patient had a medical history of lung carcinoma and had taken 6 cycles of chemotherapy and 5 cycles of radiation therapy. A chest radiography showed some right hilar enlargement. On further evaluation and assessment, using computed tomography scan of the thorax with radiographic contrast showed a nonencasing filling defect in the SVC which was suggestive of SVCS.

The patient was taken to the cardiac catheterization laboratory where venous access was obtained through the right antecubital vein. Intravenous heparin was given to achieve desired activated clotting time. The mean pressure in the cephalic SVC was 20 mmHg. By passing a JR4 diagnostic catheter, SVC venogram was performed which revealed 90% occlusion with thrombus [Figure 1]a. Stenting of the SVC was planned. The lesion was crossed using a straight tip 0.035 inch hydrophilic wire (Terumo, Japan). JR4 diagnostic catheter was advanced in the RA, and mean pressure obtained was 6 mmHg. Later, the straight tip Terumo wire was exchanged for a 0.035? Amplatz Super Stiff Guidewire (Boston Scientific Corporation, USA). A 45 cm long 6F Pinnacle sheath (Terumo, Japan) was advanced through the right antecubital vein and a 14 mm × 60 mm Epic self-expandable stent (Boston Scientific Corporation, USA) was deployed in the SVC [Figure 1]b. Postdilatation was done using a 12 mm × 40 mm Mustang Percutaneous Transluminal Angioplasty (PTA) catheter (Boston Scientific Corporation, USA) at 12 atm [Figure 1]c. End result was optimal [Figure 1d]. There was no pressure gradient between the SVC and RA. The patient remained hemodynamically stable throughout procedure. She experienced prompt, dramatic relief of symptoms. By the following morning, there was resolution of facial and upper extremity swelling. The patient was discharged with normal hemodynamics and advised follow-up after 6 months. Duplex Doppler study done after 6 months during follow-up revealed normal flow at the stented segment.
Figure 1: Case I (a) SVS stenosis with thrombus profiled (arrow). (b) Stenting in progress. (c) Instent balloon dilatation in progress. (d) End result

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Case II

A 49-year-old female presented with a history of bilateral arm edema, facial edema, and dyspnea, which began 6 months ago; she also gave a history of low-grade fever for 1 month. The patient was normotensive and nondiabetic. Before her admission, she was investigated for her symptoms. Chest radiography showed hilar enlargement, which was followed by high-resolution computed tomography which showed partially occlusive chronic thrombosis of the SVC and multiple mediastinal lymph nodes. On further evaluation by biopsy of the lymph nodes, Hodgkin's lymphoma was confirmed.

The patient was subjected to stenting of SVC stenosis using the right upper limb vein approach. The mean pressure in the cephalic SVC was 22 mmHg. By passing a 5F pigtail catheter, SVC venogram was performed which showed 99% occlusion measured about 13 mm in length and was 2 cm above the SVC and RA junction [Figure 2]a. Intravenous heparin was given to achieve an activated clotting time 300 s. 5F pigtail was exchanged for JR4 diagnostic catheter to cross the lesion and the mean RA pressure obtained was 5 mmHg. The lesion was crossed using a straight tip 0.035" hydrophilic wire (Terumo, Japan) which was exchanged for a 0.035" Amplatz Super Stiff Guidewire (Boston Scientific Corporation, USA). A 45 cm 6F Pinnacle sheath (Terumo, Japan) was advanced through the right antecubital vein through which 14 mm × 60 mm Epic self-expandable stent (Boston Scientific Corporation, USA) was deployed in the SVC [Figure 2]b. Postdilatation was done using a 12 mm × 40 mm Mustang PTA catheter (Boston Scientific Corporation, USA) at 14 atm [Figure 2]c. The result obtained was optimal [Figure 2]d. The patient remained hemodynamically stable during the procedure. She experienced prompt, relief of symptoms. By the following morning, there was resolution of facial and upper extremity swelling and her dyspnea. The patient was discharged and advised follow-up after 6 months. She was referred to the medical oncologist for the medical management of Hodgkin's lymphoma. Duplex Doppler study done after 6 months during the follow-up revealed normal flow at the stented segment.
Figure 2: Case II (a) SVS stenosis with thrombus profiled (arrow). (b) Stenting in progress. (c) Instent balloon dilatation in progress. (d) End result

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  Discussion Top


Percutaneous stenting was introduced as a less invasive method for the management of SVC obstruction. Patients with malignant SVCS are usually seriously ill, and further deterioration is likely due to the presence of unresectable advanced malignant tumors.[9] Stent placement relieves the obstruction immediately which in fact helps relieving the symptomatic status of the patient. As radiation and chemotherapy are only modestly effective for SVCS secondary to unresectable advanced malignant tumors, stent placement is a better alternative for relieving the symptoms and increasing quality of life of affected patients. The peri- and post-procedural complication rates are about 6%.[10]

We have performed SVC stenting using the upper limb venous approach instead of conventional femoral approach. Femoral venous approach has been the preferred approach for SVC stenting because of the ease of access and maneuverability of bulky hardware such as large bore sheath and stent. However, while injecting contrast, the distal segment of the lesion and the distal landing segment of the stent cannot be defined with precision. Subclavian route has also been used; however, there is a risk for developing pneumothorax. Although we faced the limitation of maneuvering the bulky sheath through the smaller lumen, we realized the distinct advantage of observing the antegrade blood flow in SVC. It helped us in precise measurement of the stenosis and deployment of the distal landing segment of the stent near SVC-RA junction. We could successfully finish both the procedures by limiting the contrast injection to the minimum.

To conclude, upper limb venous approach can be a good alternative approach for SVC stenting with some limitations and some distinct advantages. As this approach has been used anecdotally, a study involving more number of cases done through this route can help giving a better insight for this approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hunter W. The history of an aneurysm of the aorta with some remarks on aneurysms in general. Med Obs Enq 1757;1:323-57.  Back to cited text no. 1
    
2.
Baker GL, Barnes HJ. Superior vena cava syndrome: Etiology, diagnosis, and treatment. Am J Crit Care 1992;1:54-64.  Back to cited text no. 2
    
3.
Parish JM, Marschke RF Jr, Dines DE, Lee RE. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc 1981;56:407-13.  Back to cited text no. 3
    
4.
Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: Clinical characteristics and evolving etiology. Medicine (Baltimore) 2006;85:37-42.  Back to cited text no. 4
    
5.
Cheng S. Superior vena cava syndrome: A contemporary review of a historic disease. Cardiol Rev 2009;17:16-23.  Back to cited text no. 5
    
6.
Kee ST, Kinoshita L, Razavi MK, Nyman UR, Semba CP, Dake MD. Superior vena cava syndrome: Treatment with catheter-directed thrombolysis and endovascular stent placement. Radiology 1998;206:187-93.  Back to cited text no. 6
    
7.
Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007;356:1862-9.  Back to cited text no. 7
    
8.
Charnsangavej C, Carrasco CH, Wallace S, Wright KC, Ogawa K, Richli W, et al. Stenosis of the vena cava: Preliminary assessment of treatment with expandable metallic stents. Radiology 1986;161:295-8.  Back to cited text no. 8
    
9.
Armstrong BA, Perez CA, Simpson JR, Hederman MA. Role of irradiation in the management of superior vena cava syndrome. Int J Radiat Oncol Biol Phys 1987;13:531-9.  Back to cited text no. 9
    
10.
Uberoi R. Quality assurance guidelines for superior vena cava stenting in malignant disease. Cardiovasc Intervent Radiol 2006;29:319-22.  Back to cited text no. 10
    


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