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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 1  |  Issue : 4  |  Page : 112-114

Thrombectomy and angioplasty as treatment for acute superior vena cava syndrome


1 Department of Specialized and General Surgery, Fluminense Federal University, Niterói, RJ, Brazil
2 Department of Clinical Research, Federal University of Uberlandia, Uberlandia, SP, Brazil
3 Vascular Clinic Ocke Reis, Rio de Janeiro, RJ, Brazil

Date of Submission10-Aug-2016
Date of Acceptance08-Nov-2016
Date of Web Publication3-Jan-2017

Correspondence Address:
Paulo Eduardo Ocke Reis
Department of Specialized and General Surgery, Fluminense Federal University, Niterói, RJ 24033-900
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-5585.197497

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  Abstract 

Superior vena cava syndrome (SVCS), a disease caused by obstruction of the venous blood influx, because of benign etiology, from the upper body into the right atrium, is becoming more frequent, with growing use of central catheters. The present study is a case report of such acute SVCS managed successfully with an endovascular approach. A 53-year-old male patient, who had received a central venous catheter into the right jugular vein for chemotherapy, revealed an extensive thrombus formation in the veins and was diagnosed of grade 2 SVCS. He was subjected to local thrombolysis therapy followed by mechanical thrombectomy with adjunctive catheter-guided aspiration and a stent being placed through balloon angioplasty. The patient revealed a complete relief of symptoms, excellent signs of clinical improvement, and no signs of recurrence till date, 6 months posttherapy. This case supports the feasibility, safety, and efficacy of endovascular thrombectomy and angioplasty to treat SVCS.

Keywords: Aspiration thrombectomy, endovascular repair, pharmacological management, superior vena cava syndrome, thrombosis


How to cite this article:
Reis PO, Roever L, Nascimento MR, Sandri Pd. Thrombectomy and angioplasty as treatment for acute superior vena cava syndrome. Transl Surg 2016;1:112-4

How to cite this URL:
Reis PO, Roever L, Nascimento MR, Sandri Pd. Thrombectomy and angioplasty as treatment for acute superior vena cava syndrome. Transl Surg [serial online] 2016 [cited 2019 Jan 21];1:112-4. Available from: http://www.translsurg.com/text.asp?2016/1/4/112/197497


  Introduction Top


Superior vena cava syndrome (SVCS) is a disease caused by obstruction of the venous blood influx from the upper body into the right atrium. Though malignancy is the principal cause, in about 22%-40% of the cases, the disease can be caused due to benign conditions such as central venous catheters, thrombosis, extrinsic compression, dialysis fistulas, granulomatous infection, fibrosing mediastinitis, or pacing electrodes. [1],[2] Malpositioning of indwelling central catheter and the intraluminal fibrosis of the device may result in central venous occlusion, which invariably leads to SVCS. Upper body and head elevation, oxygen therapy, oral anticoagulation, or steroid administrations can relieve symptoms by decreasing soft tissue swelling. Although surgical reconstruction has been reported, the endovascular treatment with stent has shown rapid relief from symptoms and is considered as the treatment of choice for critical patients. [2],[3],[4]


  Case Report Top


A 53-year-old man presented to the emergency department at Sγo Lucas Hospital in Copacabana, Rio de Janeiro, Brazil, on November 2015, with breathlessness, cough, fatigue, and recent edema in face and neck region. History revealed the placement of a central venous catheter into his right internal jugular vein for chemotherapy to treat a colon tumor 1 month ago. Contrast-enhanced spiral or multi-slice computed tomography (CT) [Figure 1] showed extensive thrombus in the superior vena cava (SVC; the catheter tip), brachiocephalic venous trunk, left subclavian, lower portion of the left internal jugular vein, and filling defect in the right external jugular vein. The patient was diagnosed of central venous catheter-induced acute SVCS. An endovascular approach was opted to treat the patient using double access; a right common femoral vein approach, using a 9-F sheath, and the left basilic vein approach, using a 6-F sheath. A 5000-unit bolus of heparin was administered at the beginning of the intervention. A venogram was obtained from the arm access that demonstrated thrombosis along the left subclavian vein [Figure 2]. Treatment approach opted was pharmacomechanical thrombolysis with recombinant tissue plasminogen activator (rtPA) catheter-directed thrombolysis and rapid clot removal utilizing a percutaneous mechanical device (Aspirex™ S-Straub Medical Aspirex ® S Catheters Aspirex). Thrombolysis was successfully performed [Figure 3]. We used diluted doses of rtPA, total 30 mg, administered very slowly during 2 h throughout the surgery. The use of rtPA was aimed to create a passage to accomplish aspiration and for subsequent balloon angioplasty. A pig tail catheter was inserted from the femoral access, and a central venogram was obtained showing critical lesions of the SVC and proximal right brachiocephalic vein (rBCV) and an incompletely opened left brachiocephalic vein (lBCV) before balloon angioplasty [Figure 4]. Subsequently, from the basilic access, a progressive balloon angioplasty was performed in the SVC, rBCV, and lBCV with 5 mm × 60 mm, 7 mm × 100 mm, and 10 mm × 60 mm balloons, respectively (Power Flex Cordis Corporation, Miami, FL, USA). A noncompliant balloon was used to postdilate a stent, 14 mm × 80 mm (Smart Control, Cordis Corporation, Miami, FL, USA), and a balloon, 14 mm × 40 mm (Maxi LD Cordis Corporation, Miami, FL, USA), in SVC and lBCV, respectively [Figure 5]. Due to extensive fibrosis, rBCV was treated by balloon angioplasty alone, with no stent. Venous drainage was done in SVC and lBCV, where the stent was placed. At the immediate postoperative clinical follow-up examination, his SVC symptoms were found completely resolved. A follow-up CT, obtained at 2 months, demonstrated stent patency [Figure 6], and clinical visit at 6 months revealed no signs of recurrence. Our follow-up periods were 1, 2, and 6 months and in the future will be followed up every year. Informed consent was obtained from the patient.
Figure 1. Coronal computed tomography image of the chest, demonstrating fibrosis compressing the superior vena cava (red arrow)

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Figure 2. Venography through the left subclavian vein

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Figure 3. Superior vena cava access after pharmacomechanical thrombolysis with recombinant tissue plasminogen activator catheter-directed thrombolysis and rapid clot removal utilizing a percutaneous mechanical device (Aspirex™ S-Straub Medical Aspirex® S Catheters Aspirex)

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Figure 4. Venogram shows critical lesions of the superior vena cava and proximal right brachiocephalic vein (arrow) and an opened left brachiocephalic vein after balloon angioplasty

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Figure 5. From left to right, progressive balloon angioplasty, first in the superior vena cava, right brachiocephalic vein and left brachiocephalic vein showing critical stenoses, in detail in the superior vena cava and next the critical superior vena cava lesion opening with noncompliant balloon of 14 mm × 4 cm Maxi LD (Cordis Corporation, Miami, FL, USA)

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Figure 6. Clinical condition of the patient at (a and b) and before intervention; (c and d) immediately after the procedure; and (e and f) 2 months after the intervention showing complete relief of the symptoms and stent patency

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  Discussion Top


At present, repeated balloon angioplasty with stent placement and endovascular revascularization of the SVC represents the therapy of choice for patients who develop severe SVCS. [2],[3],[4],[5] However, despite repeated interventions, restenosis may still occur, and hence an endovascular repair, which is less invasive, seems an appropriate primary treatment for benign SVC syndrome with stenting as the first line of treatment. [2] A wide range of stents have been used in relieving SVCS, a vast majority of which are uncovered stents, which are of two types: Self-expanding and balloon expanding. [6] In the present report, we opted for self-expanding stents after pharmacomechanical thrombolysis and balloon angioplasty. However, covered stent's use has been cited in literature. [7] Newer tools used for pharmacomechanical thrombolysis have shown promising results in reducing the thrombus load. [8] Thrombolysis can be achieved by delivering thrombolytic agents at the site of the clot, through a catheter, which allows more effective local action, notably in the acute phase, as observed in the present case. [7] An unilateral stenting was used in this case because of extensive fibrosis in rBCV [Figure 5]. In a previous study, authors evaluated bilateral versus unilateral stenting in the treatment of malignant SVCS and concluded that unilateral stent placement was clinically more effective as it had lower rates of complications and recurrence. [9] The prior literature confirms the results observed in this case report that the use of a combined procedure to open the acutely thrombosed SVC could rapidly alleviate symptoms in seriously ill SVCS patients. [8] In this study, the authors used both pharmacological and mechanical thrombolysis (catheter-directed thrombolysis with a percutaneous mechanical device) with primary stenting to manage acute SVCS patient, with success. [8] Depending on the clinical presentation, the SVCS can be managed through medical or surgical intervention. As agreed by previous studies, in acute presentations, <2 weeks of duration, better results are obtained, especially with catheter-directed, pharmacomechanical thrombolysis technique. [10],[11]

In conclusion, SVCS is caused due to occlusion or severe stenosis of the SVC or BCVs, even due to benign causes. The present case supports the technical and clinical feasibility, safety and efficacy of endovascular thrombectomy and angioplasty to treat SVCS.

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.
Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: Clinical characteristics and evolving etiology. Med Baltimore 2006;85(1):37-42.  Back to cited text no. 1
    
2.
Rizvi AZ, Kalra M, Bjarnason H, Bower TC, Schleck C, Gloviczki P. Benign superior vena cava syndrome: Stenting is now the first line of treatment. J Vasc Surg 2008;47(2):372-80.  Back to cited text no. 2
    
3.
Breault S, Doenz F, Jouannic AM, Qanadli SD. Percutaneous endovascular management of chronic superior vena cava syndrome of benign causes: Long-term follow-up. Eur Radiol 2016;27(1):97-104.[DOI: 10.1007/s00330-016-4354-y].  Back to cited text no. 3
    
4.
Valentin LI, Kuban JD, Ramanathan R, Whigham CJ. Endovascular treatment of bilateral pulmonary artery stenoses and superior vena cava syndrome in a patient with advanced mediastinal fibrosis. Tex Heart Inst J 2016;43(3):249-51.  Back to cited text no. 4
    
5.
Tonak J, Fetscher S, Barkhausen J, Goltz JP. Endovascular recanalization of a port catheter-associated superior vena cava syndrome. J Vasc Access 2015;16(5):434-6.  Back to cited text no. 5
    
6.
Rachapalli V, Boucher LM. Superior vena cava syndrome: Role of the interventionist. Can Assoc Radiol J 2014;65(2):168-76.  Back to cited text no. 6
    
7.
Gwon DI, Paik SH. Successful treatment of malignant superior vena cava syndrome using a stent-graft. Korean J Radiol 2012;13(2):227-31.  Back to cited text no. 7
    
8.
O'Sullivan GJ, Mhuircheartaigh JN, Ferguson D, Delappe E, O'Riordan C, Browne AM. Isolated pharmacomechanical thrombolysis plus primary stenting in a single procedure to treat acute thrombotic superior vena cava syndrome. J Endovasc Ther 2010;17(1):115-23.  Back to cited text no. 8
    
9.
Dinkel HP, Mettke B, Schmid F, Baumgartner I, Triller J, Do DD. Endovascular treatment of malignant superior vena cava syndrome: Is bilateral wall stent placement superior to unilateral placement? J Endovasc Ther 2003;10(4):788-97.  Back to cited text no. 9
    
10.
Kokotsakis J, Chaudhry UA, Tassopoulos D, Harling L, Ashrafian H, Vernandos M, Kanakis M, Athanasiou T. Surgical management of superior vena cava syndrome following pacemaker lead infection: A case report and review of the literature. J Cardiothorac Surg 2014;9:107.  Back to cited text no. 10
    
11.
Madkaiker AN, Krishna N, Jose R, Balasubramoniam KR, Murukan P, Baquero L, Varma PK. Superior vena cava syndrome caused by Pacemaker Leads. Ann Thorac Surg 2016;101(6):2358-61.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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