Management of Superior Vena Cava Syndrome Perspective from vascular surgery

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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

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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 - PowerPoint PPT Presentation

Transcript of Management of Superior Vena Cava Syndrome Perspective from vascular surgery

Page 1: Management of Superior Vena Cava Syndrome  Perspective from vascular surgery

Management of Superior Vena Cava Syndrome Perspective from vascular surgery

Joint Hospital Surgical Grand RoundDr NG Kit Yu AlbertTuen Mun Hospital27th October 2012

Page 2: Management of Superior Vena Cava Syndrome  Perspective from vascular surgery

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

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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

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Page 5: Management of Superior Vena Cava Syndrome  Perspective from vascular surgery

Case Presentation

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Causes of SVCS

• Malignant (80-90%)– bronchogenic carcinoma– metastatic pulmonary malignancy– metastatic mediastinal malignancy– lymphoma– leukaemia

• Benign (10-20%)

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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

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Presenting signs and symptoms

Oncologic emergencies, Michael T. McCurdy et alCrit Care Med 2012 Vol. 40, No. 7

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Imaging for SVCS

• CT– identify pathology and extent of involvement– demostration of collaterals

• MRI• Doppler ultrasound

– identify thrombosis– reverse flow in subclavian vein

• Venogram

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Treatment options

• Malignant causes– supportive measures

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

– chemotherapy– radiotherapy– corticosteriods– endovascular intervention– surgical bypass

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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

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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 necess

ary after PTA alone

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

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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

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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.

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Safety and effectiveness of vascular endoprosthesis for malignant superior vena cava syndromeN P Nguyen et alThorax 2009;64:174–178

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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

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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

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Endovascular intervention for SVCS

Safety and effectiveness of vascular endoprosthesis for malignant superior vena cava syndromeN P Nguyen et alThorax 2009;64:174–178

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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?

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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

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Venous bypass for SVCS

• Extra-anatomical bypass– internal jugular / axillary vein femoral /

external iliac vein– avoid sternotomy

• morbidities• avoid mediastinal pathology

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Management of Superior Vena Cava Syndrome by Internal Jugular to Femoral Vein BypassRajinder Singh Dhaliwal et alAnn Thorac Surg 2006;82:310–2

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Venous bypass for SVCS

Superior vena cava syndrome: Relief with a modified saphenojugular bypass graftJean M. Panneton et alJ Vasc Surg 2001;34:360-3

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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?

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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

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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

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Case Presentation

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Case Presentation

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Summary

• Superior vena cava syndrome– uncommonly need vascular intervention– endovascular intervention showed promising

results in published data– operative bypass as last resort

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Thank you

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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