Ann Thorac Surg 2003;75:158-161
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Stent placement in superior vena cava syndrome
Patrick Courtheoux, MDa,
Barbara Alkofer, MDb,
Madjed Al Refaï, MDb,
Radj Gervais, MDc,
Jean Philippe Le Rochais, MDb,
Philippe Icard, MD*b
a Department of Neuroradiology, CHRU de Caen, Caen, France
b Department of Thoracic Cardiovascular Surgery, CHRU de Caen, Caen, France
c Department of Thoracic Oncology, Centre François Baclesse, Caen, France
Accepted for publication August 13, 2002.
* Address reprint requests to Dr Icard, Department of Thoracic and Cardiovascular Surgery, CHRU de Caen, Côte de Nacre, 14033 Caen, France.
e-mail: icard-p{at}chu-caen.fr
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Abstract
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BACKGROUND: Superior vena cava syndrome (SVCS) is often seen in the natural history of malignant thoracic diseases. SVCS is characterized by unpleasant symptoms that usually lead to death. The purpose of our study is to show the efficiency of percutaneous stenting in the superior vena cava for relieving SVCS and the possibility of repeated stenting after recurrence.
METHODS: Twenty patients with SVCS caused by malignant diseases who had one or more stents placed in the superior vena cava or its main tributaries were evaluated.
RESULTS: Out of 20 patients, 1 died of myocardial infarction 24 hours after the procedure without any signs of pulmonary embolus, hemorrhage, or malposition of the stent. SVCS was successfully controlled in 94% of patients until death or completion of the study. In 3 patients the procedure was repeated (3 to 20 weeks later) because of the recurrence of symptoms.
CONCLUSIONS: Percutaneous venous stent placement in the superior vena cava is a simple and effective technique to relieve rapid SVCS caused by malignancies. When recurrence occurs, repeated stenting can be performed successfully.
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Introduction
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Superior vena cava syndrome (SVCS) is a very unpleasant condition. The prognosis for SVCS is usually very poor when it is caused by thoracic and mediastinal malignancies [1]. SVCS is characterized by swelling of the face, neck, and arms, with dyspnea, cough, and collateral thoracic circulation. Treatment with radiation therapy and chemotherapy may produce an initial relief [2], whereas operations with bypass are associated with high mortality and morbidity [3]. Although venous endoprothesis has become a new therapeutic option, few series have been reported to date [4–10]. Even though SVCS is often treated by radiologists, thoracic and vascular surgeons must be aware of this technique. We report our clinical experience with 20 patients of malignant SVCS who underwent SVC stenting. We emphasize the fact that the procedure can be repeated successfully during cancer evolution.
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Patients and methods
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From March 1998 to November 2001, 20 patients with stenosis of the superior vena cava and or its main tributaries underwent placement of a self-expandable endovascular prosthesis. The clinical characteristics of the patients are summarized in Table 1. There were 18 males and 2 females with a mean age of 58 years (range, 35 to 74 years old). All patients had swelling of the face and neck with venous distention. One patient presented hoarseness and another patient had cerebral edema. The SVCS was caused by malignant disease in all patients: broncho-pulmonary cancers in 16 (11 squamous cell carcinomas, 3 adenocarcinomas, and 2 undifferentiated carcinomas), metastases from colonic cancers in 2, metastases from esophageal cancer in 1, and invasive mediastinal germ cell cancer in the remaining patient. The mechanism of SVCS was caused by either lymph node compression of the vena cava in 16 patients or direct compression of the vena cava by mediastinal invasive cancer in 4. In the weeks and months before stent placement, all patients except 1 (patient 17) had received chemotherapy and 10 patients (50%) had had an associated radiation therapy at a dose ranging from 30 to 50 Gray. Three patients also had a past history of resectional operations. Diuretics and steroids were administered to all patients, but this failed to relieve the SVCS. Computed tomographic scan always documented the level and size of the vena cava obstruction.
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Table 1. Characteristics of 20 Patients Suffering from Superior Vena Cava Syndrome Related to Malignant Diseases Who Underwent a Wallstent Placement
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Stent placement technique
Informed consent was obtained from all patients. The procedure was performed with local anesthesia. Patients were monitored for blood pressure, electrocardiogram, and oxygen saturation. The stent was introduced into the right common femoral vein through a 9-French sheath (Medicorp, Villers-les-Nancy, France). A 0.035-inch hydrophilic, angled guidewire (Terumo, Tokyo, Japan) was used to pass the stenosed vessel. A vena cava cavogram was systematically realized by femoral injection with opacification of the brachiocephalic confluence (Fig 1).
In 3 patients (1, 9, and 19), angioplasty was performed to dilate the stenosis before stent positioning. The type and size of the stent was decided according to the information given by the pre-therapeutic computed tomographic scan and the vena cava cavogram. We used self-expanding Wallstents (Schneider, Bulach, Switzerland) in all patients. The length of the stents ranged from 2 to 10 cm, whereas the diameter ranged from 9 mm to 16 mm. As later described, two stents were placed in 2 patients (patients 1 and 19) and three stents in 1 patient (patient 20). A final vena cavogram always confirmed the patency of the tent, showing that the stent placement was correct in all patients with sufficient caliber of the stenosed vessel (Fig 2).
Intravenous heparin was administered to all patients (5000 IU bolus) at the beginning of the procedure, followed by an infusion of 1000 IU per hour for the first 24 hours to maintain the heparin plasma level at twice the normal thromboplastin level. On day 2 after the procedure, low molecular weight heparin was administered and continued for at least 1 month, and then oral anticoagulation therapy (warfarin and aspirin) was given.
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Fig 1. Preoperative vena cava opacification before stenting. See the stenosis of the superior vena cava.
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Results
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No complications occurred during the procedure, such as occlusion or migration of the stent. Patient 17 died 24 hours after the procedure from acute heart failure with signs of myocardial infarction on electrocardiographic examination, and failure of the left ventricular function on ultrasound examination, without any signs of pulmonary embolus. There was no sign of bleeding and the stent was well positioned on chest roentgenograms.
SVCS symptoms were relieved immediately and completely in all patients except for 1 (patient 15). This patient experienced a thrombosis of the stent 48 hours after the procedure, and the patient’s condition was considered too poor to be restented. Therefore, SVCS was successfully controlled in 18 of 19 patients. Fifteen patients died with a mean survival time of 76 days (range, 1 to 300 days), and 5 patients, patients 10, 12, 14, 18, and 20 were alive at 180 days, 14 days, 27 days, 120 days, and 30 days, respectively after the procedure. One patient suffered from hemoptysis caused by the anticoagulant therapy, which was resolved by decreasing the dosage.
Recurrence of SVCS and repeated stenting
Among the 18 patients whose SVCS was immediately relieved after stenting, 3 patients (patients 1, 19, and 20) experienced a recurrence of the symptoms (from 3 weeks to 5 weeks after the first stent placement as later described). Two patients (patients 1 and 19) successfully underwent an insertion of a new stent, and patient 20 needed a third stent to treat the SVCS.
In patient 1, who had received chemotherapy and radiation therapy (40 Gray) for bulky N2 nodes with squamous cell carcinoma, an SVCS developed caused by the stenosis of the origin of the left brachiocephalic vein. Although a wall stent was placed successfully, the patient had recurrence of the SVCS 3 weeks later because of the compression of the right brachiocephalic vein. A new wall stent was inserted in the right brachiocephalic vein at the Y-junction beside the other stent with immediate resolution of the SVCS. The patient died 2 months later from progressive cancer without occlusion of the stents.
In patient 19, a SVCS appeared caused by a stenosis of the right inominate vein. Although a wall stent was placed successfully, the SVCS reoccurred because of a complete obstruction of the right subclavian vein and its left confluence. The subclavian vein was desobstructed with angioplasty, and a wall stent was placed in the left confluence 5 weeks after the first one. The patient died 15 days after the second stent placement of his advanced cancer disease.
In patient 20, three stents were used to treat his SVCS. The SVCS was caused by a complete obstruction of the SVC. The first wall stent was placed with a good initial angiographic result, but 1 month later the SVCS reappeared because of a neoplasic invasion of the stent. Another stent was placed successfully into the first one relieving the SVCS symptoms. Ten days later the endoprothesis was reobstructed, and it was desobstructed with another wall stent placed into the previous one with a lot of difficulty. The patient was still alive 30 days after the third stent placement.
Finally the SVCS was successfully controlled in 94% of patients (18 of 19) until death or completion of the study.
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Comment
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Because SVCS is mainly caused by advanced lung and mediastinal cancers, it is generally associated with poor prognosis [1]. As shown in our study, the mean survival time was 76 days. Therefore good palliation is the main objective. When radiation therapy and chemotherapy are inefficient to improve SVCS, other techniques must be discussed. Caval replacement or bypass are too hazardous and risky [3] in patients with invasive cancers, bad condition, and poor prognosis. So an endovascular stent has now become the procedure of choice because it is less invasive, simpler, and safer, as shown in our series as well as in others reports [4–10]. Radiation therapy was used in only 50% of patients before stenting, because the choice of our oncologists is to start chemotherapy as soon as possible in patients with SVCS caused by advanced lung cancer, rather than mediastinal radiation therapy that usually delays the beginning of chemotherapy. Radiation therapy may improve the signs of SVCS, but its results are often delayed (2 to 3 weeks), and sometimes it fails. When the association of radiation and chemotherapy is chosen, early resolution of symptoms by stent positioning highly eases the injection of a high amount of fluid needed for such treatment. As indicated in Table 2,
SVCS was relieved immediately in most of the reported patients. Our 94% rate of patency and our 20% recurrence rate are similar to those reported in other series (78% to 100% of patency and 6.7% to 21% of recurrence). In a case of thrombosis, repeated stenting can be done. Also thrombolysis can be attempted [2, 3]. When direct tumor ingrowth occurs, it can be treated with balloon angioplasty, as was done with 3 patients in our study.
Finally percutaneous venous stent placement in the superior vena cava is a safe and simple palliative procedure for treating SVCS, when it is caused by advanced cancer disease. This procedure must be known especially by thoracic surgeons who are often confronted with such patients suffering from malignant SVCS with poor prognosis. Palliation of symptoms is achieved immediately in the large majority of patients. Complications are rare and usually minor. When occlusion of the stent occurs, endovascular thrombectomy, thrombolysis, or dilatation with second stenting must be discussed.
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References
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- Stock K.W., Jacob A.L., Proske M., et al. Treatment of malignant obstruction of the superior vena cava with the self-expanding wallstent. Thorax 1995;50:1151-1156.[Abstract]
- Chacon J.I., Garcia L., Lanciego C., et al. Treatment of the superior and inferior vena cava syndromes of malignant cause with wallstent catheter placed percutaneously. Am J Oncol 1997;20:293-297.
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Abstract
Introduction
