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.