Endovascular stent-based revascularization of malignant superior vena cava syndrome with concomitant implantation of a port device using a dual venous approach

Editor's Choice - A Systematic Review and Meta-analysis of 24 Month Patency After Endovenous Stenting of Superior Vena Cava, Subclavian, and Brachiocephalic Vein Stenosis

OBJECTIVE

This systematic review and meta-analysis aimed to appraise recent evidence assessing patency outcomes at various time points in patients with superior vena cava, subclavian, and brachiocephalic vein stenosis who had undergone stenting.

DATA SOURCES

PubMed, Scopus, and Cochrane Library databases were searched for studies up to December 2022.

REVIEW METHODS

Measured outcomes included technical success rate, primary, primary assisted, and secondary patency at various time points. A subgroup analysis was also conducted to compare malignant and benign obstruction. GRADE was used to assess the certainty of evidence.

RESULTS

Thirty nine studies reporting outcomes in 1 539 patients were included in the meta-analysis. Primary patency up to one year after the procedure was 81.5% (95% CI 74.5 - 86.9%). Primary patency declined after one year to 63.2% (95% CI 51.9 - 73.1%) at 12 - 24 months. Primary assisted patency and secondary patency at ≥ 24 months were 72.7% (95% CI 49.1 - 88.0%) and 76.6% (95% CI 51.1 - 91.1%). In the subgroup analysis, primary patency was significantly higher in patients with a malignant stenosis compared with a benign stenosis at 1 - 3 and 12 - 24 months. No significant difference was seen for pooled secondary patency rates when comparing the malignant and benign subgroups. GRADE analysis determined the certainty of evidence for all outcomes to be very low.

CONCLUSION

Stenting is an effective intervention for benign and malignant stenosis of the superior vena cava, subclavian, and brachiocephalic veins. Primary patency rates were good up to one year after the procedure, with 81.5% of stents retaining patency at 6 - 12 months. Patency rates declined after one year, to 63.2% primary and 89.3% secondary patency at 12 - 24 months, showing improved outcomes following re-intervention. High quality evidence is lacking. More research is needed to investigate patency outcomes and the need for surveillance or re-intervention programs.

Interventions for superior vena cava syndrome

Superior vena cava (SVC) syndrome refers to the clinical manifestations of cerebral venous hypertension secondary to obstruction of the SVC and/or the innominate veins. The most common cause of SVC syndrome is malignancy like small cell lung cancer and non-Hodgkin lymphoma, but there is an increasing trend of benign etiologies secondary to thrombosis due to central lines/ pacemakers or mediastinal fibrosis. Supportive measures include head elevation, diuresis, supplemental oxygen, and steroids. Thrombolysis with or without endovenous stenting is required emergently in those with airway compromise or symptoms secondary to cerebral edema. Definitive treatment in those with malignancy is multidisciplinary; this requires radiotherapy, chemotherapy, SVC stenting, oncologic surgery and SVC bypass or reconstruction. Endovascular treatment is the primary modality for palliation in malignancy and in those with benign etiology. Surgery is reserved for those who have failed or are unsuitable for endovascular treatment. In patients with benign disease endovenous stenting and open surgery provide excellent symptom relief and are safe and effective.

Endovascular Stenting in Superior Vena Cava Syndrome: A Systematic Review and Meta-analysis

PURPOSE

Endovascular stenting has been used to manage superior vena cava syndrome for several decades and has become standard firstline practice. This study aims to investigate the outcomes of endovascular stenting in the management of superior vena cava syndrome (SVCS).

METHODS

MEDLINE, EMBASE and PUBMED online databases were searched, with studies involving more than ten adult patients included. Studies identified spanned 27 years, from 1993 to 2020. Meta-analyses were performed based on Clopper-Pearson estimation.

RESULTS

Fifty-four studies were identified, for a total of 2249 patients, of which 2015 had malignant SVCS and 222 benign SVCS. Pooled technical success and clinical success rates were 96.8% (95% CI 96.0-97.5%) and 92.8% (95% CI 91.7-93.8%). Technical success and clinical success rates for studies investigating benign SVCS alone were identical at 88.8% (95% CI 83.0-93.1%). Pooled patency remained above 90% for the first year. Average complication and re-intervention rates were 5.78% (SD = 9.3182) and 9.11% (SD = 11.190).

CONCLUSIONS

This review confirms the effectiveness of endovascular stenting in managing SVCS. Further directions of research may include specific outcomes of endovascular stenting in benign SVCS, and the impact of procedural characteristics, such as the use of anticoagulation and type of stent used, on outcomes.

LEVEL OF EVIDENCE

Level III, systematic review of retrospective cohort studies.

Endovascular therapy for superior vena cava syndrome: A systematic review and meta-analysis

BACKGROUND

Superior vena cava (SVC) syndrome is caused by the obstruction of the SVC and can result in significant morbidity and mortality. In contemporary practice, endovascular therapy (ET) has become the standard of care for a majority of these patients. This study is a systematic review and meta-analysis of the available literature to assess technical success, restenosis, and recurrence of SVC syndrome following endovascular intervention.

METHODS

For this meta-analysis, we conducted a systematic literature review of PubMed, Cochrane Library, and Embase databases from inception to April 14, 2021 for studies on ET for SVC syndrome. Studies included full-length journal articles on the use of ET among adults with SVC syndrome. Case reports or case series with fewer than 20 patients were excluded. We evaluated the endpoints of technical success rate, restenosis rate, and recurrence rates in SVC syndrome patients after endovascular stenting. The results of this study were calculated using random-effects models.

FINDINGS

We identified 6,012 reports, of which 39 studies met our inclusion criteria and were included for analysis. A total of 2200 patients received ET for SVC syndrome. The weighted technical success rate was 98.8% (95% CI 98.2-99.3) with low heterogeneity (I²=17.4%, p = 0.185), restenosis rate was 10.5% (95% CI 8.4-12.6) with moderate heterogeneity (I²=53.5%, p<0.001), and recurrence rate was 10.8% (95% CI 8.1-13.5) with high heterogeneity (I²=75.8%, p<0.001). Total complication rate was 8.6% (95% CI 7.3%-9.9%) with a mean complication rate of 7.5% (95% CI 4.7%-10.3%).

INTERPRETATION

Our systematic review revealed high technical success, low restenosis, and low recurrence rates following ET. Collectively, these results support the paradigm of ET as an effective and safe treatment for patients with SVC syndrome.

FUNDING

None.