SVC Stenosis and Endovascular Therapy: A Better Alternative Than Surgery!

Superior vena cava (SVC) syndrome can be exceptionally debilitating for patients. Open surgery for this problem carries a high risk of morbidity and mortality. Endovascular approaches have allowed for successful treatment of this problem with a tremendous decrease in the complication rate as compared to surgical approaches, but there is a risk of perforation and life-threatening bleeding. In addition, I have been involved in a case in which a stent migrated into the atrium. So case planning is essential for the perfect result and the perfect result does not necessarily mean complete elimination of stenosis.

I would like to share an interesting case we recently performed. A young male bilateral lung transplant recipient had developed chronic SVC syndrome from indwelling venous catheters to treat his underlying pulmonary disease. We asked for a collaborative from a couple of specialties. We asked his lung transplant surgeon to be available in case of a perforation. He had a prior clamshell incision for his transplant and a redo chest would be a potentially dangerous situation. We also had perfusion available in case cardiopulmonary bypass was needed and anesthesia prepared for the possibility of a sternotomy, although 2 venous sheaths could fix the whole problem if the case went smoothly.

Diagnostic venography revealed a high-grade SVC stenosis (Figure 1). A snare was used to gain through and through wire access from the right internal jugular vein to the right common femoral vein. An angioplasty was followed by stent placement. We selected a 10 mm x 38 mm stent (iCAST™, Atrium Medical Corporation, Hudson, New Hampshire) that was post-dilated with a 12 mm balloon (Figures 2 and 3).

The patient had an excellent result with no complications. It’s our belief that pre-case planning helped avoid any issues during the procedure.

How would you handle this case?

_____________________________________________________________________________

ROSS MILNER, MD, FACS

Ross Milner, MD, FACS is associate professor of surgery at Loyola University Chicago Stritch School of Medicine. He was recruited to Loyola from Emory University School of Medicine in Atlanta, where he was associate professor of surgery.

Dr. Milner graduated Cum Laude from the University of Pennsylvania, where he also completed medical school. He was chief resident in surgery at the Hospital of the University of Pennsylvania. He completed fellowships at the University of Pennsylvania and University Medical Center in Utrecht in the Netherlands. Dr. Milner is currently Chief of the Division of Vascular Surgery and Endovascular Therapy at Loyola University Medical Center, Stritch School of Medicine in Chicago, Illinois.

Comments

Dear Ross:

Good case. I have not used atrium in these cases. Good stent. I wonder how the covered stent would fair against standard stents. I am sometimes afraid of covered stents migrating, but have no experience. We had a Wallstent migrated last decade where we had to get access above and below with a rim catheter in order to pull the stent folded back down the groin.

Michael
Thanks for your note. I am concerned about migration as well. I think the "body-floss" wire technique here helped prevent this issue.
Ross

Procedural success in the norm for endovascular intervention for central stenosis, with the real problem being that of maintaining patency. Restenosis is the rule rather than the exception.

I'm interested to see whether covered stenting in this application has any effect on these trends. Comparative trials are necessary in order to answer that question.

Meredith
Thanks for your comment. I am hoping that a covered stent approach will eliminate this issue.
Ross

Nice Case. I have done multiple SVC complete occlusion cases, and the results are dramatic with marked clinical improvement post venous decompression. Most of my cases are dialysis pts with an upper extremity AV access.

I have been successful with using a 14 mm Smart Stent or a 14 mm Luminexx. This precludes excluding critical collaterals (when present- such as azygous vein) which may be helpful in case of restenosis. The ends flare better above and below. I would predilate with an 8 mm balloon to make sure the lesion is responsive and to facilitate passage of stent. (For tight occlusions, somtimes 3-4mm low profile balloon angioplasty over .014 wire necessary). Then I would post dilate with a 12, and if it well tolerated, further post dilate to a 14. Both these stents are likely to focally fixate within the lesion and unlikely to migrate (if 40 mm in length, centered on the lesion), unlike the Wallstent which tends to watermelon as a complete unit. Deploying from below via CFV approach over a guidewire securely advenced into the subclavian or jugular vein will allow one to securely flare stent above the stenosis and minimize catastrophic migration.

There is always a concern for life threatening pericardial rupture and tamponade, which is why if a covered stent is not used, one should consider having one on standby. However, rupture unlikely if kept to 14 mm after tolerating 12 mm PTA

I do believe in general a 14 mm stent would be better choice then a 12 mm stent, as native SVC likely much larger, which is why I would choose the 14 mm Smart Stent or Luminexx over the 12 mm Atrium.. Back up emergency stents would be a 13 mm Viabahn or 14 mm Wallgraft.

Of course, as the larger Atrium stents become available in 14 and 16 mm sizes, these may become better choices.

I am unaware of any data on restenosis rates for SVC stents

Congratulations on a very nice result!

David
Thanks for your comments and suggestions. I could not comfortably inflate to larger than to 12 mm due to the inflation pressures. I agree that covered stents do help minimize catastrophic complications.
Ross

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SVC Stenosis and Endovascular Therapy: A Better Alternative Than Surgery!

Superior vena cava (SVC) syndrome can be exceptionally debilitating for patients. Open surgery for this problem carries a high risk of morbidity and mortality. Endovascular approaches have allowed for successful treatment of this problem with a tremendous decrease in the complication rate as compared to surgical approaches, but there is a risk of perforation and life-threatening bleeding. In addition, I have been involved in a case in which a stent migrated into the atrium. So case planning is essential for the perfect result and the perfect result does not necessarily mean complete elimination of stenosis.

I would like to share an interesting case we recently performed. A young male bilateral lung transplant recipient had developed chronic SVC syndrome from indwelling venous catheters to treat his underlying pulmonary disease. We asked for a collaborative from a couple of specialties. We asked his lung transplant surgeon to be available in case of a perforation. He had a prior clamshell incision for his transplant and a redo chest would be a potentially dangerous situation. We also had perfusion available in case cardiopulmonary bypass was needed and anesthesia prepared for the possibility of a sternotomy, although 2 venous sheaths could fix the whole problem if the case went smoothly.

Diagnostic venography revealed a high-grade SVC stenosis (Figure 1). A snare was used to gain through and through wire access from the right internal jugular vein to the right common femoral vein. An angioplasty was followed by stent placement. We selected a 10 mm x 38 mm stent (iCAST™, Atrium Medical Corporation, Hudson, New Hampshire) that was post-dilated with a 12 mm balloon (Figures 2 and 3).

The patient had an excellent result with no complications. It’s our belief that pre-case planning helped avoid any issues during the procedure.

How would you handle this case?

_____________________________________________________________________________

ROSS MILNER, MD, FACS

Ross Milner, MD, FACS is associate professor of surgery at Loyola University Chicago Stritch School of Medicine. He was recruited to Loyola from Emory University School of Medicine in Atlanta, where he was associate professor of surgery.

Dr. Milner graduated Cum Laude from the University of Pennsylvania, where he also completed medical school. He was chief resident in surgery at the Hospital of the University of Pennsylvania. He completed fellowships at the University of Pennsylvania and University Medical Center in Utrecht in the Netherlands. Dr. Milner is currently Chief of the Division of Vascular Surgery and Endovascular Therapy at Loyola University Medical Center, Stritch School of Medicine in Chicago, Illinois.

Comments

Dear Ross:

Good case. I have not used atrium in these cases. Good stent. I wonder how the covered stent would fair against standard stents. I am sometimes afraid of covered stents migrating, but have no experience. We had a Wallstent migrated last decade where we had to get access above and below with a rim catheter in order to pull the stent folded back down the groin.

Michael
Thanks for your note. I am concerned about migration as well. I think the "body-floss" wire technique here helped prevent this issue.
Ross

Procedural success in the norm for endovascular intervention for central stenosis, with the real problem being that of maintaining patency. Restenosis is the rule rather than the exception.

I'm interested to see whether covered stenting in this application has any effect on these trends. Comparative trials are necessary in order to answer that question.

Meredith
Thanks for your comment. I am hoping that a covered stent approach will eliminate this issue.
Ross

Nice Case. I have done multiple SVC complete occlusion cases, and the results are dramatic with marked clinical improvement post venous decompression. Most of my cases are dialysis pts with an upper extremity AV access.

I have been successful with using a 14 mm Smart Stent or a 14 mm Luminexx. This precludes excluding critical collaterals (when present- such as azygous vein) which may be helpful in case of restenosis. The ends flare better above and below. I would predilate with an 8 mm balloon to make sure the lesion is responsive and to facilitate passage of stent. (For tight occlusions, somtimes 3-4mm low profile balloon angioplasty over .014 wire necessary). Then I would post dilate with a 12, and if it well tolerated, further post dilate to a 14. Both these stents are likely to focally fixate within the lesion and unlikely to migrate (if 40 mm in length, centered on the lesion), unlike the Wallstent which tends to watermelon as a complete unit. Deploying from below via CFV approach over a guidewire securely advenced into the subclavian or jugular vein will allow one to securely flare stent above the stenosis and minimize catastrophic migration.

There is always a concern for life threatening pericardial rupture and tamponade, which is why if a covered stent is not used, one should consider having one on standby. However, rupture unlikely if kept to 14 mm after tolerating 12 mm PTA

I do believe in general a 14 mm stent would be better choice then a 12 mm stent, as native SVC likely much larger, which is why I would choose the 14 mm Smart Stent or Luminexx over the 12 mm Atrium.. Back up emergency stents would be a 13 mm Viabahn or 14 mm Wallgraft.

Of course, as the larger Atrium stents become available in 14 and 16 mm sizes, these may become better choices.

I am unaware of any data on restenosis rates for SVC stents

Congratulations on a very nice result!

David
Thanks for your comments and suggestions. I could not comfortably inflate to larger than to 12 mm due to the inflation pressures. I agree that covered stents do help minimize catastrophic complications.
Ross

Add new comment

Back to top