Treatment of malignant obstruction of the superior vena cava with the self-expanding Wallstent.

Abstract

Background -Obstruction of the superior vena cava (SVC) in malignant disease can cause considerable distress to patients. Symptomatic relief can be achieved by the percutaneous implantation of a selfexpanding stent (Wallstent) into the stenosis. Methods -Fourteen patients with obstruction ofthe SVC were treated with one to three Wallstent endoprostheses. They suffered from advanced bronchogenic carcinoma (n = 12), thyroid carcinoma (n = 1), and breast carcinoma (n = 1). The indication for stent placement was symptomatic obstruction of the SVC and incurable disease. Stenting was performed for symptom relief, and before, during, and after courses of radiotherapy or chemotherapy as needed. Results -Twelve patients experienced complete symptomatic relief within two days of stent placement. Two patients did not benefit. Three patients not given anticoagulation developed stent thrombosis between one week and eight months after initial placement, and within one day of endobronchial stent implantation with bronchial laser therapy or balloon dilatation in all three. Patency of the SVC was achieved again by a repeat procedure. Conclusions -Stent placement for obstruction of the SVC gives rapid symptomatic relief. Subsequent endobronchial stent implantation with bronchial laser therapy or balloon dilatation could be a risk for caval stent occlusion. Stent thrombosis remains a problem in patients who are not anticoagulated.

Superior Vena Cava Syndrome. From the Bronchus to the Vessel

“…Stent insertion leads to a clinical improvement of the venous congestion in 71% [24] to 100%, analyzing the present papers the overall success rate is estimated to be over 90% (Table II). Clinical features of SVCS are reported to decrease markedly within 48 h after the procedure [6,18,23] (Fig. 5).…”

“…Benign causes include tuberculous mediastinitis, syphilitic aortic aneurysms, mediastinal fibrosis, post-irradiation fibrosis, posttraumatic strictures, and intrathoracic goiter [14][15][16][17][18]. Iatrogenic causes for SVCS like catheter manipulations, pacemaker wire implantation, and aortic valve replacement must also be taken into consideration [19][20][21].…”

“…The venography (Fig. 2) is an invasive procedure and is usually performed simultaneously via both cubital veins [1,5,18,23,24]. Its disadvantages are the use of iodinated contrast media with the inherent risk of anaphylactic reaction and the increased risk of thrombus formation [14].…”

“…[5,22,50] to prevent thrombotic re-occlusion in patients who had severe thrombosis of the SVC prior to stenting or where thrombi were seen at post interventional cavography. Oral anticoagulation was performed during 3 or 6 months following stent implantation in patients with pre-stenting thrombosis [18,23]. Others did not perform oral anticoagulation at all, even if thrombotic occlusion was present prior to stent implantation [52].…”

“…If more than one stent is used the most distal one is placed first followed by the more proximal ones in an overlapping arrangement [7]. Once the stent is in place a dilatation balloon inside the stent may be used to accelerate it's expansion and dilatate any remaining stricture [5,7,18,23]. [5,22,50] to prevent thrombotic re-occlusion in patients who had severe thrombosis of the SVC prior to stenting or where thrombi were seen at post interventional cavography.…”