1. 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

2. Case Presentation 54 years old gentleman
Case of end stage renal failure on haemodialysis
Right brachial artery to cubital vein arteriovenous fistula (AVF) creation complicated 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

3. 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

5. Case Presentation

6. Anatomy of superior vena cava
~2cm in diameter
~7cm in length
Thin wall
Low intravascular pressure
Enclosed in tight compartment

7. Causes of SVCS Malignant (80-90%) bronchogenic carcinoma
metastatic pulmonary malignancy
metastatic mediastinal malignancy
lymphoma
leukaemia
Benign (10-20%)

8. 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

9. Presenting signs and symptoms
Oncologic emergencies, Michael T. McCurdy et al
Crit Care Med 2012 Vol. 40, No. 7

10. Imaging for SVCS CT identify pathology and extent of involvement
demostration of collaterals
MRI
Doppler ultrasound
identify thrombosis
reverse flow in subclavian vein
Venogram

11. Treatment options Malignant causes supportive measures
e.g. head elevation, fluid restriction, diuretics
chemotherapy
radiotherapy
corticosteriods
endovascular intervention
surgical bypass

12. 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

13. 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 are between 17% and 30% for angioplasty alone
secondary interventions are frequently necessary after PTA alone

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

15. Endovascular intervention for SVCS
Vascular stent for SVCO in NSCLC patients
Retrospective study involving 17 patients
Laurent Greillier et al Respiration 2004;71:178–183

16. Endovascular intervention for SVCS
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.

17. Safety and effectiveness of vascular endoprosthesis for malignant superior vena cava syndrome
N P Nguyen et al
Thorax 2009;64:174–178

18. Endovascular intervention for SVCS
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

19. Endovascular intervention for SVCS
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

20. Endovascular intervention for SVCS
Safety and effectiveness of vascular endoprosthesis for malignant superior vena cava syndrome
N P Nguyen et al
Thorax 2009;64:174–178

21. Endovascular intervention for SVCS
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?

22. Venous bypass for SVCS
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

23. Venous bypass for SVCS Extra-anatomical bypass
internal jugular / axillary vein  femoral / external iliac vein
avoid sternotomy
morbidities
avoid mediastinal pathology

24. 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

25. Venous bypass for SVCS
Superior vena cava syndrome: Relief with a modified saphenojugular bypass graft
Jean M. Panneton et al
J Vasc Surg 2001;34:360-3

26. Venous bypass for SVCS
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?

27. Case Presentation 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

28. Case Presentation
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

29. Case Presentation

30. Case Presentation

31. Summary Superior vena cava syndrome
uncommonly need vascular intervention
endovascular intervention showed promising results in published data
operative bypass as last resort

32. Thank you

33. Type 1: partial obstruction of the SVC with antegrade flow through the azygos vein
Type 2: near complete obstruction of the SVC with antegrade flow though the azygos vein
Type 3: complete obstruction of the SVC with reversed flow through the azygos vein
Type 4: complete obstruction of the SVC and azygos vein with development of chest wall and internal mammary collaterals

34. Etiology of central vein thrombosis in 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