Endovascular treatment of superior vena cava syndrome: case report and review of the literature
(Portuguese PDF version)

Marco Aurélio Cardozo,1 Eduardo Lichtenfels,2 Nilon Erling Jr.,3 Dorvaldo P. Tarasconi4

1. Professor, Vascular Surgery, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil. Vascular and endovascular surgeon, Santa Casa de Porto Alegre (ISCMPA), Porto Alegre, RS, Brazil.
2. Resident in Vascular Surgery, FFFCMPA-ISCMPA, Porto Alegre, RS, Brazil.
3. Vascular surgeon. PhD student, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.
4. Interventional radiologist, ISCMPA, Porto Alegre, RS, Brazil.

This study was presented at the International Congress of Endovascular Surgery, held in São Paulo, Brazil, from April 20 to 22, 2006.

Correspondence:
Marco Aurélio Cardozo
Rua Marquês do Pombal, 1199/401
CEP 90540-001 - Porto Alegre, RS, Brazil
Tel./Fax: 55 51 3337.2306
E-mail: macardozo@terra.com.br

ABSTRACT

We report a case of a patient with symptomatic benign superior vena cava syndrome treated by the endovascular technique. The angiographic resonance before angioplasty showed extensive thrombosis of the left brachiocephalic trunk, left subclavian vein and superior vena cava obstruction close to the right brachiocephalic trunk. The patient underwent radical mastectomy 2 years ago with adjuvant chemotherapy and chest radiotherapy. Venous angioplasty and balloon-expandable stenting were performed. Satisfactory result was obtained with immediate relief of symptoms due to recanalization of the right brachiocephalic trunk and superior vena cava. Oral anticoagulation was initiated. The patient is still asymptomatic after 8 months of follow-up. The endovascular treatment is a therapeutic alternative with low morbidity and satisfactory mid-term results that can be offered to patients with superior vena cava syndrome.

Keywords: Angioplasty, vena cava, stenosis.

J Vasc Bras. 2006;5(4):308-12

Article submitted June 20, 2006, accepted September 6, 2006.

 

INTRODUCTION

Benign superior vena cava syndrome (SVCS) represents 5-22% of cases.1-5 Among the main benign causes are mediastinal fibrosis,6,7 postradiation sequela, central venous catheters, pace makers, arteriovenous fistulas and hemodialysis catheters.1,2,8,9

Treatment of SVCS has been indicated for symptomatic patients. Initial management includes clinical measures that aim at mitigating symptoms and reducing the edema in the territory drained by the superior vena cava (SVC). Conventional surgical treatment is still the most frequently used therapy for cases refractory to less invasive treatments, especially in younger patients.5,9,10

Due to low morbidity rate and to satisfactory medium-term results, venous angioplasties have become the preferential palliative treatment for malignant SVCS. Endovascular treatment has been successfully used in benign cases of post-thrombotic lesions, postoperative fibrotic scars and after long-term indwelling catheters, intimal hyperplasia and venous lesions after radiotherapy. However, analyses of series with greater number of patients and long-term outcome assessment are needed to establish the real benefits of this therapy in patients with SVCS.8,11-13

This study aims at demonstrating a case of benign SVCS successfully treated using the endovascular technique, besides reviewing the literature.


CASE REPORT

A 72-year-old patient, female reported edema, flare, pressure on her head and neck and edema of upper limbs with worsening over the past 6 months. She reported exacerbation of symptoms at the horizontal position and when she lowered her head.

She was submitted to radical right mastectomy with axillary lymphadenectomy associated with adjuvant chemotherapy and radiotherapy due to breast carcinoma in 2003. Chemotherapy was performed through long-term catheter inserted in the left subclavian vein for approximately 4 months.

After the clinical diagnosis of SVCS, the patient was submitted to an angiographic resonance for anatomical study of the case and therapeutic planning. The examination revealed extensive thrombosis of the brachiocephalic trunk (BCT), of the left subclavian vein and obstruction of the SVC next to the right BCT (Figure 1).

click hereFigure 1 - Preoperative phlebography

The treatment consisted of venous angioplasty with stent placement. We performed an approach of the right brachial vein, passage of a hydrophilic guide wire through the obstruction area, predilatation with 5 x 10 mm cutting balloon (Boston Scientific®) and implantation of a 10 x 25 mm balloon-expandable stent (Boston Scientific-Express LD®) (Figure 2). At intraoperative control phlebography, there was complete recanalization of the right BCT and SVC (Figure 3).

click hereFigure 2 - Dilatation and placement of balloon-expandable stent

click hereFigure 3 - Control phlebography

The patient presented significant relief of symptoms and was discharged after 48 h; she was anticoagulated. She remains asymptomatic after 8 months of follow-up. On patient's request, we did not perform imaging examination during the follow-up.


DISCUSSION

The etiological diagnosis is crucial to establish the best therapy for the patient with SVCS.

The initial treatment of benign SVCS includes the use of supportive clinical measures, which aim at reducing the edema in the region drained by the SVC, therefore reducing the syndrome symptoms.5,9

Indication for revascularization surgery in malignant SVCS is limited due to the high morbidity and mortality rate and to short patients' survival.9 In cases of mediastinal neoplasia in which there is the possibility of healing the disease, resection with venous revascularization is the treatment of choice.14

Over the past years, with the evolution of balloon-catheters and stents, transluminal percutaneous angioplasty has become an important therapeutic alternative for patients with SVCS. Angioplasty promotes fast symptom relief without the need of major surgical procedure.15,16

The preference for the use of self-expandable or balloon-expandable stent remains an issue to be debated. Self-expandable stents are more flexible and have larger diameters, besides expanding and adapting themselves to the venous wall throughout time. Balloon-expandable stents present a more precise release and more radial force, reducing the risk of recoil.17 Venous thrombolysis using fibrinolytic drugs before stent angioplasty is not mandatory, besides being an efficacious alternative in cases of extensive occlusion with presence of large amounts of thrombi.18 Venous predilatation with angioplasty balloon-catheter is restricted to occlusions and to very extensive stenoses, in which it might be impossible to pass the stent release system. Immediate stent placement can prevent distal embolization.17,19

Angioplasty with stent in malignant SVCS is recommended in cases with acute symptoms,12 failure of the conventional treatment or recurrent symptoms, which occurs in 50% of cases.3 For some authors, this conduct should always be considered, since it is a palliative treatment for patients with low life expectancy.20

In benign SVCS, indication for angioplasty is still controversial.10,11 The fact that patients are young and present high life expectancy requires a procedure with good long-term outcome. Conventional venous revascularization surgery with graft is still the standard treatment with which all other techniques should be compared.5,11,17,21 Nowadays, it is recommended to initially submit those patients to angioplasty with or without stent placement, associated with anticoagulation. None of those procedures prevents a future venous revascularization.10,11,15

The results of angioplasty and stent placement for the treatment of SVCS have been assessed by several studies. Complete resolution of the syndrome is reported in 68-100% of cases.12,22-25 Clinical success ranges between 5526 and 93%.12 The initial technical success of the endovascular treatment ranges from 90 to 100% in the literature. General patency rate is around 77-85%, and assisted patency between 85 and 91%, with a 17-month follow-up.11,18,26 Recurrent stenosis rates ranges from 0 to 45%.22,23 In patients with lesions associated with hemodialysis, recurrent stenosis rate ranges between 60 and 80%.27

Long-term results of the endovascular treatment of SVCS were presented by Smayra et al. The authors treated 16 patients with malignant SVCS, five benign and nine caused by hemodialysis. One-year patency rate was 74% for malignant SVCS, 50% (75% assisted) for benign and 22% (56% assisted) for patients undergoing hemodialysis. Complications occurred in 7% of the patients.17

Bornak et al. reported the treatment of nine patients with benign SVCS using the endovascular technique. Stent placement was necessary in all cases due to insufficient result after isolated angioplasty. Six-month patency was 100%, and in 12-month patency was 67% (100% assisted).16

Complications related to stent placement are uncommon, ranging between 7 and 19%.17,18,26 Stent migration is a rare, but severe complication, and may lead to death.1,10,11

Anticoagulation after venous recanalization is not consensual. Most authors suggest a protocol of anticoagulating patients with heparin during the procedure and for 24-72 h, maintaining a platelet aggregation inhibitor (AAS 75-250 mg/day) for 1-3 months after the surgery.16

Follow-up should be performed using clinical examination and imaging study. Color-flow Doppler ultrasonography has 100% sensitivity and specificity to detect recurrent stenoses in the venous segment accessible at examination. Phlebography, multislice magnetic angiographic resonance can be used to complement the investigation and plan a new intervention in cases of venous recurrent stenosis or failure of initial therapy. Although magnetic angiographic resonance presents the disadvantage of imaging artifact of the metal stent, it is the method of choice to investigate patients with loss of renal function.16

We conclude that the endovascular treatment is a therapeutic alternative that can bring benefits to patients with benign central venous obstructions in selected cases. Endovascular intervention is safe and presents good short- and medium-term patency rates, associated with low morbidity and mortality rates.


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