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Management of Superior Vena Cava Syndrome Perspective from vascular surgery. Joint Hospital Surgical Grand Round Dr NG Kit Yu Albert Tuen Mun Hospital 27 th October 2012. Case Presentation. 54 years old gentleman Case of end stage renal failure on haemodialysis

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Management of superior vena cava syndrome perspective from vascular surgery

Management of Superior Vena Cava Syndrome Perspective from vascular surgery

Joint Hospital Surgical Grand Round

Dr NG Kit Yu Albert

Tuen Mun Hospital

27th October 2012


Case presentation
Case Presentation

  • 54 years old gentleman

  • Case of end stage renal failure on haemodialysis

  • Right brachial artery to cubital vein arteriovenous fistula (AVF) creationcomplicated by graft infection with graft removal

  • Left brachial artery to median cubital vein AVF creation, complicated with AVF stenosis with angioplasty done

  • Multiple episodes of temporary catheter insertion over neck


Case presentation1
Case Presentation

  • Complained of rapid increase in facial swelling and dyspnea, clinically compatible with SVCO

  • CT venogram done

    • left brachiocephalic vein near complete obstruction

    • right brachiocephalic vein complete obstruction

    • superior vena cava obstruction



Causes of svcs
Causes of SVCS

  • Malignant (80-90%)

    • bronchogenic carcinoma

    • metastatic pulmonary malignancy

    • metastatic mediastinal malignancy

    • lymphoma

    • leukaemia

  • Benign (10-20%)


Causes of svcs1
Causes of SVCS

  • Benign

    • mediastinal fibrosis

    • vascular diseases

      • e.g. aortic aneurysm, large-vessel vasculitis

    • infections

      • histoplasmosis, tuberculosis, syphilis, actinomycosis…

    • benign mediastinal tumors

      • teratoma, cystic hygroma, thymoma, dermoid cyst…

    • thrombosis from central venous catheters, pacemaker leads, and guidewires


Presenting signs and symptoms
Presenting signs and symptoms

Oncologic emergencies, Michael T. McCurdy et al

Crit Care Med 2012 Vol. 40, No. 7


Imaging for svcs
Imaging for SVCS

  • CT

    • identify pathology and extent of involvement

    • demostration of collaterals

  • MRI

  • Doppler ultrasound

    • identify thrombosis

    • reverse flow in subclavian vein

  • Venogram


Treatment options
Treatment options

  • Malignant causes

    • supportive measures

      • e.g. head elevation, fluid restriction, diuretics

    • chemotherapy

    • radiotherapy

    • corticosteriods

    • endovascular intervention

    • surgical bypass


Treatment options1
Treatment options

  • Benign causes

    • supportive measures + treat underlying causes

    • thrombolytic therapy followed by anticoagulation

      • for acute thrombotic event <2 days

      • successful thrombolysis was demonstrated in 70% of the patients

    • endovascular intervention

    • operative bypass


Endovascular intervention for svcs
Endovascular intervention for SVCS

  • Venoplasty and venous stenting

  • Provide rapid relief of symptoms

    • 24-72 hours after placement

  • Restoration of a diameter of 12 to 14 mm resolves symptoms

  • Primary patency rates at 12 months arebetween 17% and 30%for angioplasty alone

    • secondary interventionsare frequently necessary after PTA alone


Carlos Lanciego et al Endovascular Stenting as the First Step in the Overall Management of Malignant Superior Vena Cava Syndrome


Endovascular intervention for svcs1
Endovascular intervention for SVCS Step in the Overall Management of Malignant Superior Vena Cava Syndrome

  • Vascular stent for SVCO in NSCLC patients

  • Retrospective study involving 17 patients

Laurent Greillier et al Respiration 2004;71:178–183


Endovascular intervention for svcs2
Endovascular intervention for SVCS Step in the Overall Management of Malignant Superior Vena Cava Syndrome

  • Outcome

    • malignant SVC syndrome

      • Nagata et al., 71 patients

      • primary and secondary patency rates of 88% and 95%

      • over a mean survival period of 5.4 months

Nagata T, Makutani S, Uchida H, Kichikawa K, Maeda M, Yoshioka T, Anai H, Sakaguchi H, Yoshimura H.

Follow-up results of 71 patients undergoing metallic stent placement for the treatment of a malignant obstruction of the superior vena cava.

Cardiovasc Intervent Radiol 2007;30:959–67.


Safety and effectiveness of vascular endoprosthesis for malignant superior vena cava syndrome

N P Nguyen et al

Thorax 2009;64:174–178


Endovascular intervention for svcs3
Endovascular intervention for SVCS malignant superior vena cava syndrome

  • Outcome

    • benign SVC syndrome

      • Bornak et al., 9 patients

        • one-year patency of 67%

        • two patients requiring repeated interventions for recurring symptoms

      • Sheikh et al. 19 patients

        • mid-term patency of 93% with a median follow-up of 29 month

        • three patients requiring repeated interventions


Endovascular intervention for svcs4
Endovascular intervention for SVCS malignant superior vena cava syndrome

  • Complications

    • airway compromise, pulmonary embolism

    • superior vena cava rupture, hemoperiocardium and tamponade

    • stent related

      • malposition, migration, fracture

    • access site related

    • anticoagulation related

    • average: minor 3.2%, major 7.8%

      • Ganeshan et al., superior vena cava stenting for SVC obstruction: current status


Endovascular intervention for svcs5
Endovascular intervention for SVCS malignant superior vena cava syndrome

Safety and effectiveness of vascular endoprosthesis for malignant superior vena cava syndrome

N P Nguyen et al

Thorax 2009;64:174–178


Endovascular intervention for svcs6
Endovascular intervention for SVCS malignant superior vena cava syndrome

  • Rapid relief of symptoms

  • Studies limited to case reports and small series only

  • Lack of results of long term follow up

  • Questions to ask

    • long term results for benign cases?

      • long term sequlae with stent in situ

    • balloon only or + stent in benign cases?


Venous bypass for svcs
Venous bypass for SVCS malignant superior vena cava syndrome

  • Reserved for patients whose symptoms are refractory to anticoagulation and endovascular treatment

  • Internal jugular to right atrium / SVC bypass

    • spiral saphenous vein graft

    • expanded polytetrafluoroethylene graft

  • Extra-anatomical bypass


Venous bypass for svcs1
Venous bypass for SVCS malignant superior vena cava syndrome

  • Extra-anatomical bypass

    • internal jugular / axillary vein  femoral / external iliac vein

    • avoid sternotomy

      • morbidities

      • avoid mediastinal pathology


Management of Superior Vena Cava Syndrome by Internal Jugular to Femoral Vein Bypass

Rajinder Singh Dhaliwal et al

Ann Thorac Surg 2006;82:310–2


Venous bypass for svcs2
Venous bypass for SVCS Jugular to Femoral Vein Bypass

Superior vena cava syndrome: Relief with a modified saphenojugular bypass graft

Jean M. Panneton et al

J Vasc Surg 2001;34:360-3


Venous bypass for svcs3
Venous bypass for SVCS Jugular to Femoral Vein Bypass

  • Studies limited to case reports and small series only

  • Not much recent data in view of increasing expertize in endovascular intervention

  • Still a feasible treatment option if other treatment modalities failed

  • Questions to ask

    • comparison between traditional “open heart” vs extra-anatomical bypass?


Case presentation3
Case Presentation Jugular to Femoral Vein Bypass

  • Venoplasty + stenting planned

  • Intra-operative findings

    • right brachiocephalic vein was completely occluded from origin

    • left brachiocephalic vein about 2cm tight segmental occlusion, about 5-6cm from origin

    • failed cannulation and subsequent procedure


Case presentation4
Case Presentation Jugular to Femoral Vein Bypass

  • Left axillary vein to left external iliac vein bypass performed

    • bypass with 8mm ring supported PTFE graft

  • Post-op well with head and neck swelling subsided slowly

  • Follow up 2 months post-op

    • head and neck swelling much subsided

    • doppler signal over graft +ve


Case presentation5
Case Presentation Jugular to Femoral Vein Bypass


Case presentation6
Case Presentation Jugular to Femoral Vein Bypass


Summary
Summary Jugular to Femoral Vein Bypass

  • Superior vena cava syndrome

    • uncommonly need vascular intervention

    • endovascular intervention showed promising results in published data

    • operative bypass as last resort


Thank you

Thank you Jugular to Femoral Vein Bypass


Etiology of central vein thrombosis in hd patients
Etiology of central vein thrombosis Jugular to Femoral Vein Bypassin HD patients

  • Mechanical injury from either repeated catheter insertion or continuous catheter movement inside the vein invoking endothelial damage, subsequent inflammation, intimal hyperplasia, and fibrosis

  • Catheter or AVF related changes in the flow dynamics leading to increased shear stress, platelet aggregation, and intimal hyperplasia

  • Number of catheters inserted and increased duration of catheter days are associated with the development of thrombosis


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