Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wire stents

Application of Expandable Metallic Stents to the Venous System

Expandable metallic stents were successfully introduced in 12 patients; 6 with superior vena cava (SVC) obstruction due to tumor invasion or lymph node metastases, 3 with inferior vena cava (IVC) obstruction or stenosis due to lymph node metastases or hepatic tumor, one with common iliac vein (CIV) obstruction due to lymph node metastases, one with idiopathic obstruction of the hepatic IVC and Budd-Chiari syndrome, and one with CIV obstruction following a dialysis shunt. The length of the lesions was between 2 and 15 cm. Multiple (2–7) stents in tandem were inserted percutaneously from a femoral venous approach through a 12 to 16 F (4.0–5.3 mm) Teflon sheath. Postoperatively, all 12 patients became free from symptoms such as SVC syndrome or IVC syndrome. In 11 patients, the symptoms did not recur during the follow-up periods of 1 to 21 months.

Treatment of Tuberculous Bronchial Stenosis with Expandable Metallic Stents

Gianturco expandable metallic stents were placed in 5 patients with dyspnea on exercise due to tuberculous bronchial stenosis. The stents were placed after dilatation with a 10-mm diameter high pressure balloon catheter. In all 5 patients, obstructive changes disappeared following the procedure, and dyspnea on exercise improved markedly. No complications related to the procedure were encountered. At follow-up during a period of up to 38 months, 2 patients showed bronchial restenosis at 11 and 17 months, respectively, after stent placement. Restenosis by granulomatous tissue was successfully treated by laser ablation. One patient showed slight one-day hemoptysis 26 months after stent placement.

PTA Plus Stent Implantation Versus PTA Alone for Central Venous Stenoses

From 1990 through 1992, 17 severely stenosed central venous segments were diagnosed in 13 patients. In 9 patients, 11 stenoses were detected during follow-up after trans- femoral venous thrombectomy. The other 6 stenoses occurred in the venous outflow tract of 4 hemodialysis shunts. Six stenoses were treated by percutaneous transvenous angio plasty (PTA) alone, and 11 stenoses by PTA plus stent implantation (PTA+S). For PTA+S, a flexible, self-expanding stent was used.

Acute procedure-related complications were not observed. After a median follow-up time of eighteen months (three to thirty-six months), all patients were examined clinically, duplex-sonographically, and angiographically. Following PTA alone (n = 6), there was only 1 excellent result, and 5 patients developed high-grade restenoses. Two of these patients had to be reoperated on, and 1 patient underwent another PTA with stent placement. PTA+S (n = 11) for initial treatment of central venous stenoses gave excellent results in 8 cases, a good result in 1 case, and 2 insufficient results caused by intimal hyperplasia within the stent. These restenoses were successfully treated by another PTA.

Technical and Anatomic Factors Influencing the Success of Inferior Vena Caval Stent Placement for Malignant Obstruction

PURPOSE

To evaluate the outcomes of inferior vena cava (IVC) stent placement for malignant obstruction and to identify anatomic and procedural factors influencing technical and clinical success.

MATERIALS AND METHODS

A total of 57 patients (37 male, 20 female; age range, 22-86 y) underwent 62 IVC stent placement procedures using 97 stents (47 Wallstents, 15 S.M.A.R.T. stents, 18 Wallflex stents, 17 others) from 2005 to 2016 for malignant IVC obstruction caused by hepatic metastases (n = 22; 39%), primary hepatic malignancy (n = 16; 28%), retroperitoneal metastases (n = 16; 28%), or other primary malignancy (n = 5; 9%). Presenting symptoms included lower-extremity edema (n = 54; 95%), ascites (n = 28; 50%), and perineal edema (n = 14; 25%). Sixteen percent (n = 10) and 10% (n = 6) of the procedures involved tumor and bland thrombus, respectively.

RESULTS

Stent placements resulted in 100% venographic patency and significantly decreased pressure gradients (P < .0001). Lower-extremity swelling, perineal swelling, and abdominal distension improved within 7 days in 83% (35 of 42), 100% (9 of 9), and 40% (6 of 15) of patients, respectively, and at 30 days after the procedure in 86% (25 of 29), 89% (8 of 9), and 80% (4 of 5) of patients, respectively. Increased pre- and post-stent placement pressure gradients were associated with worse outcomes. A 4% stent misplacement rate (4 of 97) was related to the use of Wallstents with caudal stent tapering, asymmetric deployment superior to the obstruction, suprahepatic IVC involvement, and decreased stent adherence to the IVC wall as a result of local mechanical factors.

CONCLUSIONS

Stent placement is reliable, rapid, and durable in improving malignant IVC syndrome. Understanding of technical and anatomic factors can improve accuracy and avoid complications of stent misplacement.

WITHDRAWN: Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus

Authors are unable to update this review. New authors are being sought to update it.

The editorial group responsible for this previously published document have withdrawn it from publication.

Physiologic effect of stent therapy for inferior vena cava obstruction due to malignant liver tumor

PURPOSE

To understand systemic the influence of stent therapy for inferior vena cava (IVC) obstruction due to advanced liver tumor.

METHODS

Seven patients with symptomatic IVC obstruction due to advanced primary (n = 4) or secondary (n = 3) liver tumor were subjected to stent therapy. Enrollment criteria included high IVC pressure over 15 mmHg and the presence of edema and ascites. Z-stents were deployed using coaxial sheath technique via femoral venous puncture. Physiologic and hematobiochemical parameters were analyzed.

RESULTS

All procedures were successful, and the stents remained patent until patient death. Promptly after stent placement, the IVC flow recovered, and the venous blood pressure in the IVC below the obstruction level showed a significant decrease from 20.8 +/- 1.2 mmHg (mean +/- SE) to 10.7 +/- 0.7 mmHg (p < 0.01). Transient mild increase of right atrial pressure was observed in 1 patient. During the following week prominent diuresis was observed in all patients. Mean urine output volume in the 3 days before the stent therapy was 0.81 +/- 0.09 l/day compared with 2.1 +/- 0.2 l/day (p < 0.01) in the 3 days after. The edema and ascites decreased in all patients. The caval pressure change correlated well (r > 0.6) with the urine volume increase, and with the decreased volume of edema and ascites. The urine volume increase correlated well with the decrement of edema, but not with that of ascites. Improvements for various durations in the levels of blood urea nitrogen, serum creatinine, lactate dehydrogenase, fibrinogen, and platelet count were found (p < 0.05). These hematobiochemical changes were well correlated with each other and with the decrement of ascites. Two patients showed a low blood sodium level of 128.5 mEq/l after intensive natriuresis, and one of them died on day 21 with hepatic failure, which was interpreted as maladaptation aggravation. The mean survival time was 94.1 +/- 34.1 days (mean +/- SD), ranging from 21 to 140 days after stent treatment.

CONCLUSION

The stent therapy for IVC obstruction due to malignant liver tumors was followed by a series of physiologic and hematobiochemical consequences, most of them favorable but some possibly unfavorable. Rational interpretations and predictions of sequelae based on physiologic science including cardiology, hepatology, and nephrology would facilitate the best management of stent therapy for malignant IVC obstruction.

Quality Assurance Guidelines for Superior Vena Cava Stenting in Malignant Disease

Superior vena cava stenting for the treatment of malignant superior vena cava obstruction is now well established. It offers simple, rapid, and safe palliation of a distressing and potentially fatal complication of mediastinal malignant disease and compares very favorably with standard therapies such as chemotherapy and radiotherapy. The following are quality assurance guidelines for superior vena cava stenting.

Tratamento da síndrome da veia cava superior

A veia cava superior é formada pela união das duas veias inominadas, direita e esquerda, e localiza-se no mediastino médio, à direita da artéria aorta e anteriormente à traquéia. A síndrome da veia cava superior representa um conjunto de sinais (dilatação das veias do pescoço, pletora facial, edema de membros superiores, cianose) e sintomas (cefaléia, dispnéia, tosse, edema de membro superior, ortopnéia e disfagia) decorrentes da obstrução do fluxo sanguíneo através da veia cava superior em direção ao átrio direito. A obstrução pode ser causada por compressão extrínseca, invasão tumoral, trombose ou por dificuldade do retorno venoso ao coração secundária a doenças intra-atriais ou intraluminais. Aproximadamente 73% a 97% dos casos de síndrome da veia cava superior ocorrem durante a evolução de processos malignos intratorácicos. A maioria dos pacientes com a síndrome secundária a neoplasias malignas é tratada sem necessidade de cirurgia, através de radioterapia ou quimioterapia, ou através da colocação de stents endoluminais. Quando a síndrome é de etiologia benigna, o tratamento é feito através de medidas clínicas (anticoagulação, elevação da cabeça, etc.) ou, em casos refratários, através de angioplastia, colocação de stents endoluminais e cirurgia.

Thrombolysis for Central Venous Occlusion Causing Bilateral Chylothorax in a Patient with Down Syndrome

A 20-year-old woman with Down syndrome (trisomy 21) and acute lymphoblastic leukemia presented with severe respiratory compromise secondary to bilateral chylothorax as a result of central venous thrombosis and extensive upper-limb deep venous thrombosis. The chylothorax was successfully managed by catheter-directed thrombolysis and angioplasty of the venous occlusions. The development of venous thrombosis was likely to have been multifactorial. It is recognized that there is an increased incidence of congenital lymphatic anomalies in Down syndrome, which may have been a contributing factor in the development of chylothorax in this patient. This report illustrates the angiographic findings, demonstrates the successful vascular recanalization, and discusses the etiology and management of central venous thrombosis and chylothorax. The case is also presented to contribute to the expanding evidence in support of catheter-directed venous thrombolysis in selected clinical circumstances.

Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review

OBJECTIVE

To conduct a systematic review to determine the relative effectiveness of treatments currently employed in the management of superior vena caval obstruction (SVCO).

SEARCH STRATEGY

Electronic searching of the Cochrane Clinical Trials Register, Medline and Embase with identification of further studies from references cited in trials identified by electronic searching.

SELECTION CRITERIA

Both randomized and non-randomized controlled trials in which patients with carcinoma of the bronchus and SVCO had been treated with any combination of steroids, chemotherapy, radiotherapy or insertion of an expandable metal stent.

DATA COLLECTION AND ANALYSIS

There were three randomized and 98 non-randomized studies of which two and 44 respectively met the inclusion criteria.

MAIN RESULTS

Superior vena caval obstruction was present at diagnosis in 10.0% of patients with small cell lung cancer (SCLC) and 1.7% of patients with non-small cell lung cancer (NSCLC). In one small randomized trial in SCLC, the rate of SVCO relapse was not significantly reduced by giving radiotherapy on completion of chemotherapy. In another, in NSCLC, the addition of induction chemotherapy to a course of synchronous chemo-radiotherapy did not provide greater relief of SVCO. In SCLC chemotherapy and/or radiotherapy relieved SVCO in 77%; 17% of those treated had a recurrence of SVCO. In NSCLC, 60% had relief of SVCO following chemotherapy and/or radiotherapy; 19% of those treated had a recurrence of SVCO. Insertion of an SVC stent relieved SVCO in 95%; 11% of those treated had further SVCO but recanalization was possible in the majority resulting in a long-term patency rate of 92%. Morbidity following stent insertion was greater if thrombolytics were administered.

REVIEWERS' CONCLUSIONS

Chemotherapy and radiotherapy are effective in relieving SVCO in a proportion of patients whilst stent insertion may provide relief in a higher proportion and more rapidly. The effectiveness of steroids and the optimal timing of stent insertion (whether at diagnosis or following failure of other modalities) remain uncertain.

Radiological stenting provides effective palliation in malignant central venous obstruction

Malignant superior vena caval obstruction (SVCO) due to lung cancer carries a poor prognosis and response to palliative radiotherapy is variable. Eighteen patients presenting with the appearance of malignant SVCO (thirteen due to primary bronchial tumours) in a four year period from June 1995 to July 1999 underwent venography with a view to placement of an expanding metal stent under radiological control. Fourteen patients were male and four female with a mean age at presentation of 65 years (range 44-84 years). At venography only three patients had isolated SVC stenosis, fivealso had brachiocephalic, internal jugular or subclavian vein stenoses and one had an isolated right brachiocephalic stenosis. Venography demonstrated thrombus in eight of the remaining patients, seven in association with stenosis. In one patient stenosis of the SVC was thought to be due to radiation fibrosis as no mass was visible. All underwent Seldinger catheterization of the great veins via a right femoral puncture with deployment of the stent over a guide wire. Balloon angioplasty was performed prior to stent placement in eight patients. The eight patients with thrombus underwent thrombolysis using rt-PA (recombinant tissue-type plasminogen activator) with subsequent stent placement in seven. Radiological relief of obstruction with abolition of collateral flow was observed in all cases. One patient required further stenting for recurrent obstruction after 160 days of palliation. The median duration of palliation after stenting was 87 days. No procedure-related morbidity was observed. Thrombolysis was of value in patients with occlusive thrombus, either in isolation or complicating a malignant stricture, where radiotherapy may not have been effective. Radiological stenting is a safe technique which offers rapid palliation of SVCO.

Hemodynamic changes after self-expandable metallic stent therapy for vena cava syndrome

OBJECTIVE

We examined changes in hemodynamics after self-expandable metallic stent placement in the vena cava.

CONCLUSION

The rapid increase in venous return immediately after expandable metallic stent placement influenced the hemodynamics of the circulatory system.

Wallstent endovascular prosthesis for the treatment of superior vena cava syndrome

OBJECTIVE

We assessed the clinical outcome of self-expanding Wallstent endovascular prosthesis in the treatment of superior vena cava syndrome due to malignant tumors.

METHODS

Eleven patients with malignant superior vena cava syndrome were treated by percutaneous implantation of the self-expanding Wallstent endovascular prosthesis across the stricture site. Patency was defined by the absence of symptoms and signs of superior vena cava syndrome.

RESULTS

Ten of the 11 experienced complete symptomatic relief within 3 days of stent implantation. The remaining 1 did not benefit, and required a second procedure, dying of heart failure 5 days after stent implantation. Ten patients remain symptomatically free of superior vena cava syndrome to date or until death in follow-up lasting 17 to 227 days.

CONCLUSION

Implantation of the self-expanding Wallstent endovascular prosthesis for malignant superior vena cava syndrome provides rapid symptomatic relief and improves the patient's quality of life.

Imaging guided thoracic interventions

Interventional Radiology is a technique based medical specialty, using all available imaging modalities (fluoroscopy, ultrasound, computed tomography, magnetic resonance, angiography) for guidance of interventional techniques for diagnostic or therapeutic purposes. Actual, percutaneous transthoracic needle biopsy includes core needle biopsy besides fine needle aspiration. Any pleural, pulmonary or mediastinal fluid or gas collection is amenable to percutaneous pulmonary catheter drainage. Treatment of haemoptysis of the bronchial artery or pulmonary artery origin, transcatheter embolization of pulmonary arteriovenous malformations and pseudoaneurysms, angioplasty and stenting of the superior vena caval system and percutaneous foreign body retrieval are well established routine procedures, precluding unnecessary surgery. These techniques are safe and effective in experienced hands. Computed tomography is helpful in pre- and postoperative imaging of patients being considered for endobronchial stenting. Many procedures can be performed on an outpatient basis, thus increasing the cost-effectiveness of radiologically guided interventions in the thorax.

Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus

BACKGROUND

Superior vena caval obstruction (SVCO) is an uncommon manifestation of carcinoma of the bronchus characterised by neck swelling and distended veins over the chest. In recent years, the majority of patients with small cell lung cancer (SCLC) with SVCO at diagnosis have tended to receive chemotherapy whilst the majority of patients presenting with non-small cell lung cancer (NSCLC) and SVCO have tended to receive radiotherapy. Steroids may also be prescribed. Stenting now provides a further treatment option which may be combined with radiotherapy and chemotherapy or used on its own. The optimal timing of stenting at present is unclear.

OBJECTIVES

To determine the relative effectiveness of treatments currently employed in the management of SVCO.

SEARCH STRATEGY

Electronic searching of Cochrane Clinical Trials register, Medline and Embase. Identification of further studies from references cited in trials identified by electronic searching.

SELECTION CRITERIA

Both randomised and non-randomised controlled trials in which patients with carcinoma of the bronchus and a diagnosis of SVCO had been treated with any combination of the following treatment modalities: steroids, chemotherapy, radiotherapy or insertion of an expandable metal stent.

DATA COLLECTION AND ANALYSIS

There were 3 randomised and 98 non-randomised studies of which 2 and 44 respectively met the inclusion criteria.

MAIN RESULTS

SVCO was present at diagnosis in 10.0% of patients with SCLC and 1.7% of patients with NSCLC. In one randomised trial in SCLC, the rate of SVCO relapse was not significantly reduced by giving radiotherapy on completion of chemotherapy. In the other, in NSCLC, the addition of induction chemotherapy to a course of synchronous chemo-radiotherapy did not increase the rates of relief of SVCO. In SCLC, chemotherapy and/or radiotherapy relieved SVCO in 77%; 17% of those treated had a recurrence of SVCO. In NSCLC, 60% had relief of SVCO following chemotherapy and/or radiotherapy; 19% of those treated had a recurrence of SVCO. Insertion of an SVC stent relieved SVCO in 95%; 11% of those treated had further SVCO but recanalisation was possible in the majority resulting in a long-term patency rate of 92%. Morbidity following stent insertion was greatest if thrombolytics were administered. No study described the effectiveness of steroids in SVCO.

REVIEWER'S CONCLUSIONS

Chemotherapy and radiotherapy are effective in relieving SVCO in a proportion of patients whilst stent insertion appears to provide relief in a higher proportion and more rapidly. The optimal timing of stent insertion (whether at diagnosis or following failure of other modalities) is currently uncertain. The effectiveness of steroids in SVCO remains uncertain.

Superior vena cava stenting

Treatment of SVC obstruction with metallic stents is a rewarding procedure. The patients have symptoms that are severe and debilitating and cause significant impairment of life-style. Stent placement rapidly alleviates the symptoms of SVC syndrome and improves the patient's quality of life. The long-term patency rates have not been established; however, in patients with SVC syndrome secondary to malignant disease, stents usually remain patent for the lifetime of the patient. Recurrences can be treated with further interventional radiographic techniques. Currently, because the long-term patency rates of SVC stents are not known, most interventional radiologists tend to treat SVC stenosis from benign causes with balloon angioplasty before placing metallic stents.

Primary Gianturco stent placement for inferior vena cava abnormalities following liver transplantation

PURPOSE

To determine the efficacy of primary Gianturco stent placement for patients with inferior vena caval (IVC) abnormalities following liver transplantation.

MATERIALS AND METHODS

From August 1996 through March 1999, nine adult patients developed significant IVC abnormalities following liver transplantation. Patients were referred for vena cavography on the basis of abnormal clinical findings, laboratory values, liver biopsy results, Doppler findings, or a combination. Those patients demonstrating a significant caval or hepatic venous gradient were treated with primary Gianturco stent placement. Patients were followed clinically (nine patients), with duplex ultrasound (nine patients), vena cavography (four patients), and biopsy (seven patients).

RESULTS

Original pressure gradients ranged from 3 to 14 mm Hg, with a mean of 9 mm Hg. Gradients were reduced to 3 mm Hg or less in all nine patients; presenting signs and symptoms either resolved or improved in eight of nine patients. The ninth patient required repeated transplantation 2 days later. A second patient died 433 days after stent placement of recurrent hepatitis C. Another initially improved following caval stent placement, but underwent repeated transplantation 7 days later due to hepatic necrosis from hepatic arterial thrombosis. Follow-up for the remaining six patients has averaged 491 days, with no clinical, venographic, or ultrasound evidence for recurrent caval stenosis.

CONCLUSIONS

Intermediate term results suggest that primary Gianturco stent placement for IVC stenosis, compression, or torsion resulting after liver transplantation is safe and effective.

Reconstruction of the superior vena cava: benefits of postoperative surveillance and secondary endovascular interventions

PURPOSE

Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown.

METHODS

During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted.

RESULTS

No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively.

CONCLUSION

Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts.

Scoop biopsy of intracaval tumor thrombi: a preliminary report of a minimally invasive technique to obtain large samples

PURPOSE

The purpose of this study is to safely improve the yield of intracaval biopsy.

MATERIALS AND METHOD

A co-axial system was composed of an inner catheter with a smoothly tapered tip with a shark jaw, and an outer sheath. The biopsy procedure consisted of four steps: (1) the tip was stuck into the target thrombi; (2) the inner sheath was advanced deeply into the target and the jaw was opened within the mass; (3) the outer sheath was advanced to envelope the inner cather; (4) then the system was withdrawn. After simulation experiments seven patients underwent this scoop biopsy.

RESULTS

A simulation experiment proved that this technique brought much larger samples with minimal damage of the target surface. Seven patients who had been suspected of intracaval tumor thrombi underwent this procedure and confidential pathological examination without any complications.

CONCLUSION

This scoop biopsy procedure was thought to be helpful in obtaining large samples safely.

Stenting in malignant obstruction of superior vena cava

The treatment of patients with malignant superior vena caval obstruction with minimal morbidity has been made possible by the recent introduction of expandable metal stents as the sole palliative treatment or as an adjunct to other treatment modalities. To alleviate the distressing symptoms of superior vena caval obstruction, self-expanding metal stents were used successfully in 12 (Wallstent device in 6 and Gianturco device in 6 patients) of 13 patients. The diagnoses were small cell carcinoma (n = 4), squamous cell carcinoma (n = 4), non-Hodgkin's lymphoma (n = 1), and mesothelioma (n = 1), and a diagnosis of malignancy was not confirmed (although strongly suspected) in the remaining three cases. Eleven patients had immediate relief of obstruction and there was no change in one patient. Mean follow-up was 3.7 months (range 1 to 10 months). Excellent palliation was obtained in all but one patient in whom recurrent superior vena caval obstruction developed 3 months after stenting. Mean survival was 4.8 months (range 1 to 10 months). The ease of insertion with the use of local anesthesia with radiologic control, the self-expanding nature of the stent, and the lack of major complications on follow-up of up to 10 months are particular advantages. The self-expanding superior vena caval stents are a useful addition to our armamentarium in the management of malignant superior vena caval obstruction.

Stent-graft in the management of superior vena cava syndrome

We report the use of a Dacron-covered Gianturco-Rösch Z (GRZ)-stent to treat malignant obstruction of the superior vena cava (SVC). Initial treatment with an uncovered GRZ-stent was suboptimal due to protrusion of tumor-thrombus through the stent struts into the SVC lumen. Placement of a coaxial Dacron-covered stent graft relieved the residual obstruction due to tumor within the SVC.

Experimental study of self-expandable metallic inferior vena caval stent crossing the renal vein in rabbits. Radiologic-pathologic correlation

RATIONALE AND OBJECTIVES

The authors evaluate in the rabbit the radiologic-pathologic changes of the inferior vena cava and the renal vein and the functional changes of the kidneys after placement of a self-expandable metallic stent in the inferior vena cava where the renal vein empties.

METHODS

One self-expandable metallic stent was placed in the inferior vena cava in each of 12 rabbits; the rabbits were divided into four groups of three rabbits each. The inferior vena cava and renal vein were examined angiographically and pathologically at intervals of 1 week, 2 weeks, 1 month, and 3 months. Vena cavography was performed to evaluate changes in the inferior vena cava before and after stenting. Laboratory tests were performed to determine blood urea nitrogen and creatinine levels, and radioisotope renal scans were performed to evaluate possible changes in renal function before and after stenting.

RESULTS

No stent migration was noted in 11 of 12 rabbits; however, migration of the stent to the subdiaphragmatic level was noted in 1 rabbit. All stents were patent angiographically. Statistical analysis showed no significant change in renal function after stenting (blood urea nitrogen, P = 0.9; creatinine P = 0.5). In addition, radioisotope scans revealed no abnormal findings in perfusion and excretion. Pathologic examination of both kidneys showed no abnormal findings. Neointimal proliferation over the stent was first noted at 1 week after the stent was placed, was most prominent at 1 month, and regressed substantially by 3 months.

CONCLUSIONS

The self-expandable metallic stent was relatively well adapted to the inferior vena cava. Renal function was not affected by the inferior vena cava stent, which crossed the orifice of renal vein.

Self-expanding metal stents for palliative treatment of superior vena caval syndrome

PURPOSE

Two stent types (a new Wallstent and a Z-stent) were investigated in 30 patients with recurrent malignant superior vena caval syndrome (SVCS).

METHODS

Eligibility requirements were that the patient had recurrent symptoms after appropriate radiation therapy, chemotherapy, or both; >/= 75% of the vessel was occluded; and there was collateral flow. Because of the limited availability of stents, it was not possible to perform a prospectively randomized study.

RESULTS

In the Z-stent group (17 patients), occlusion of the stent due to acute thrombosis occurred within 12 hr in 4 patients (24%), but in the other 13 patients (76%) symptoms disappeared completely. After 2 weeks the cavogram in these patients showed no signs of thrombosis, and 12 (61%) of the patients remained symptom-free. There was partial occlusion in 5 patients (29%), without relevant clinical symptoms. Of the 13 patients who received Wallstents, only 1 had an acute immediate thrombosis (8%). Symptoms disappeared completely in the other 12 patients and no signs of thrombosis were seen. However, after 2 weeks complete stent occlusion with SVCS was found in 3 patients (23%) and partial occlusion with minor clinical symptoms in 6 (46%). Only 3 patients (23%) had complete relief of the SVCS. The difference between the rates of occlusion of the two stents after 2 weeks was highly significant (p = 0.008).

CONCLUSIONS

The overall clinical success rate for long-term patency was 100% for the Z-stents and 69% for the new Wallstent. These results suggest that when used for this purpose, the new Wallstent is more thrombogenic at 2 weeks than the Z-stent.

Endoscopic treatment of tracheal stenosis using the carbon dioxide laser and the Gianturco stent: indications and results

The self-expandable Gianturco stent was used in 11 patients with tracheal stenosis who where treated from September 1992 through July 1994. Under optical control, the stent was placed through a bronchoscope with an outside diameter of 9 mm after cross-section and dilation of the stenosis were performed with the carbon dioxide laser according to the Shapshay technique. The follow-up period varied from 3 to 22 months, with a mean of 12 +/- 6 months. Pulmonary function tests showed a mean improvement of the peak expiratory flow (50%), from 0.95+/-0.45 L/sec before the operation to 2.13+/-0.86 L/sec after the procedure. Radiologic and fibroscopic controls showed prosthesis stability. Three patients needed a second endoscopic procedure because of malposition of the stent, the formation of granuloma at the superior end of the prosthesis, and the development of a mucous membrane webbing between the two loops of a stent. Due to the lack of long-term follow-up, this technique is reserved for the treatment of severe tracheal stenosis with cartilage impairment in patients who have contraindications for external reconstructive surgery.

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

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 self-expanding stent (Wallstent) into the stenosis.

METHODS

Fourteen patients with obstruction of the 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.

Stenting of superior vena caval obstruction

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Stenosis of the inferior vena cava after liver transplantation: treatment with Gianturco expandable metallic stents

PURPOSE

Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT).

METHODS

Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses.

RESULTS

One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months.

CONCLUSIONS

Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.

A new surgical method from the viewpoint of personal identification: a case of identification based on the presence of a metallic Z-stent

To the best of our knowledge, the first case of successful personal identification based on the characteristic finding of a metallic Z-stent, unexpectedly discovered in the common bile duct, is reported. An unknown human male cadaver was found at the seaside. The age was estimated to be approximately 50-70 years and the postmortem interval was considered to be approximately 2 weeks. There was a small surgical scar of 1.5 cm in diameter in the epigastrium. The cadaver was group A in the ABO blood group system. Internally, the following severe injuries were observed: the dislocation of the occipito-atlantal joint, fractures of the cervical and thoracic portions of the spinal column, multiple fractures of the bilateral ribs, and ruptures of the spleen, left kidney and liver. Furthermore, a 4.5 cm long metallic stent was found in the common bile duct, and the gallbladder was not thoroughly identified because of the severely tight adhesion of the surrounding tissues. In every cut surface of the liver, multiple bile plaques, signifying the presence of long-standing cholestasis, were conspicuous. A microscopic examination revealed the invasion of cancer cells into the liver, which was diagnosed as well or moderately differentiated adenocarcinoma, although the primary origin of the adenocarcinoma could not be determined. The cause of his death was diagnosed as traumatic shock. According to the police investigation after the autopsy, it was revealed that a 60-year-old male, suffering from gallbladder carcinoma, had disappeared.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful treatment of prolonged superior vena cava syndrome with thrombolytic therapy: a case report

Superior vena cava (SVC) syndrome is most commonly due to direct compression of the SVC by a tumor. Recently, there has been an increase in the number of cases of SVC syndrome associated with chronic indwelling central venous catheters. We present a case history of a patient with prolonged symptoms of SVC syndrome that was successfully treated with catheter-directed (intraclot) infusion thrombolytic therapy with urokinase. The treatment, prevention, and incidence of SVC syndrome caused by thrombosis associated with catheters is discussed.

Self-expanding stents in the treatment of tracheobronchial obstruction

The self-expandable stainless steel stents (Gianturco, William Cook, Bjaeverskov, Denmark) used extensively in biliary ducts and the vascular system have recently been modified for use in the tracheobronchial tree. Between March 1991 and September 1992, six patients with unresectable tracheobronchial and mediastinal diseases were treated with the placement of one or more self-expanding stents under direct vision with a fiberoptic bronchoscope. All patients had been intubated for severe respiratory insufficiency. In all cases, immediate relief of respiratory symptoms was achieved and all patients were extubated 1 or 2 days after stent placement. Tolerance of the stents was excellent. No patient complained of pain, discomfort, or foreign body sensation. No infection or obstruction of the stents was observed. The chest roentgenogram and the bronchoscopies performed during follow-up have shown no change in the position of the stents. Our results seem promising since these devices provide effective palliation of airway obstructions and are well tolerated.

Intravascular stents in the management of acute superior vena cava obstruction of benign etiology

The purpose of our study was to report our experience with percutaneous placement of intravascular stents to relieve venous occlusion in patients with acute superior vena cava syndrome resulting from benign etiologies. Six patients ranging in age from 39 to 66 years received thrombolysis followed by placement of stents within the superior vena cava or received stent placement alone as emergency treatment for symptoms of acute superior vena cava obstruction. Treatment was successful in all patients, with establishment of a patent lumen angiographically, and patients experienced prompt symptomatic relief. Follow-up examination at intervals of 5 months to 2 years has demonstrated no evidence of reocclusion. Three patients have subsequently had central lines placed across the stented vena cava for vascular access. Percutaneous placement of intravascular stents to treat acute occlusion offered a safe and effective method of treatment in patients with superior vena cava syndrome resulting from benign causes.

Case report: superior vena caval obstruction treated by thrombolysis, mechanical thrombectomy and metallic stents

We describe a case of superior vena caval obstruction (SVCO) due to bronchial carcinoma which was complicated by extensive central venous thrombosis. Partial clot lysis was achieved with thrombolytic agents, but therapy had to be discontinued due to bleeding from the gastrointestinal tract and puncture sites. Clot dissolution was completed using the Amplatz Thrombectomy Device, and the subsequent placement of a Gianturco Z-stent resulted in prolonged symptomatic relief.

Expandable Wallstent for the treatment of obstruction of the superior vena cava

BACKGROUND

Palliative treatments for obstruction of the superior vena cava all have disadvantages. The use of a fine braided wire self expanding stent (Wallstent, Schneider (Europe) AG) in patients with malignant and benign causes of superior vena cava obstruction is reported.

METHODS

Five patients with obstruction of the superior vena cava were treated with balloon angioplasty of the stricture and the percutaneous insertion of an expandable Wallstent endoprosthesis across the site of the stricture. Four patients had advanced mediastinal malignancy previously treated by radiotherapy and one patient had fibrosing mediastinitis.

RESULTS

All patients experienced rapid symptomatic relief and, in three cases, complete palliation was achieved during survival times of seven weeks, nine weeks, and 24 weeks, respectively. Two surviving patients (with a recurrent thymoma and fibrosing mediastinitis) were free of symptoms when followed up at eight and nine months respectively.

CONCLUSIONS

Initial experience with the Wallstent endoprosthesis suggests that it is a valuable treatment alternative once conventional therapy has failed and gives rapid relief of symptoms to patients with obstruction of the superior vena cava.

Occlusive effect of metallic stents on canine ureters

A three-part study, with successive modifications based on preceding results, was conducted to evaluate ureteral placement of metallic stents. Gianturco self-expanding (10 mm and 4 mm diameter) and balloon-expanded (4 mm diameter) metallic stents were placed in normal and stenotic canine ureters. No migration or ureteral perforation occurred during the follow-up of 10 mm stents. Varying degrees of hydronephrosis and hydroureter were found on all 1-week pyelograms. At 4 weeks, complete occlusion of the stented ureter was noted in all cases because of mucosal hyperplasia around the stent wires. To prevent this reaction, 4 mm self-expanding stents constructed of smaller wire that was uncoated or coated with either Teflon or poly-urethane were tested in five dogs. In all cases, results were similar to those obtained with the larger prostheses. Finally, 4 mm balloon-expanded stents were placed in a normal ureter of three dogs. In one dog, the stent migrated out of the ureter. No migration or ureteral perforation occurred in the two remaining dogs. In these animals, mucosal hyperplasia and complete ureteral occlusion occurred 6 and 8 weeks after placement. Therefore, ureteral placement of Gianturco self-expanding as well as balloon-expanded metallic stents leads to occlusion of the ureter instead of maintaining its patency. Stents, therefore, may be useful as ureteral occlusion devices.

Treatment of a malignant stricture after esophagojejunostomy by a self-expanding metallic stent

Gianturco self-expanding metallic stents (GSs) were placed across an esophagojejunostomy which had become strictured secondary to recurrent anastomotic gastric cancer. Placement of the GS enabled the patient to take liquid food and swallow saliva, though only for a short period of time. One month after placement, the stented lumen restrictured with a markedly irregular contour. The patient's clinical status deteriorated with eventual occlusion of the stented anastomosis. The patient died of renal insufficiency 80 days after placement of the stent. There are some questions concerning the stability of applying the Gianturco-type bare stent to the digestive tract. In the future, more suitable stents will have to be developed.

Stenting in malignant vena caval obstruction

BACKGROUND

For patients with recurrent vascular obstruction of the vena cava due to tumor regrowth after chemotherapy or radiation therapy and occasionally surgery, no current therapy is available. With the development of intravascular stenting, a new option becomes available in the treatment of a vena caval syndrome.

METHODS

Twenty-two patients were treated for malignant obstruction of the vena cava by single, double, and triple Z-type metal stents. All patients had been pretreated extensively and their disease was not amenable to other therapeutic techniques at the time of stenting.

RESULTS

Correct positioning of the stents was achieved in all patients. In 68% of patients (n = 15), the symptoms completely disappeared without recurrence until death as a result of tumor progression. In 18% of patients (n = 4), a remarkable improvement was observed, but there was no complete disappearance of symptoms. In 14% of patients (n = 3), reocclusion of the vena cava occurred. The median survival time was 3.0 months (range, 1 week to 9 months).

CONCLUSIONS

The application of Z-type metal stents in patients with recurrent malignant obstruction of the vena cava appears to be a useful palliative procedure.

Expanding wire stents in benign tracheobronchial disease: indications and complications

Prosthetic tracheobronchial stents provide palliative treatment for narrowed airways where surgical resection is inadvisable. Over a 1-year period, 28 Gianturco expanding wire stents were used in 15 patients for nonneoplastic indications: pure fibrous airway stenosis (6), fibroinflammatory stenosis (4), and tracheobronchial malacia (5). Insertion was technically straightforward. A satisfactory airway lumen with immediate improvement in ventilatory function was obtained in all patients. After insertion all patients had an irritation-type cough that either subsided spontaneously (10 patients) or was successfully suppressed with inhaled corticosteroid therapy (5 patients). The most common complication (12 patients) was granuloma formation leading to stent removal in 3 patients with fibroinflammatory stenosis. Other complications were dysphagia (1), suction catheter entrapment (1), and fatal massive hemoptysis (1). At a mean follow-up of 13 months (range, 3 to 19 months) all remaining stents are functioning well with no displacement or infection. Overall results were satisfactory in pure fibrous stenoses and tracheobronchial malacia but poor in the presence of inflammation. Tracheobronchial wire stents can be successfully used in selected patients.

Gianturco self-expanding stents: clinical experience in the vena cava and large veins

Twenty-five patients with stenosis of the vena cava (21) and other large veins (4) have been treated with self-expanding Gianturco metallic stents. Eighteen patients had superior vena cava syndrome. In 17, the stricture was due to malignant superior vena cava compression recurrent after maximum tolerance radiotherapy and/or chemotherapy. In 16 of these patients there was early symptomatic relief. In 1 patient with a benign posttraumatic superior vena cava stricture, the stenosis was not relieved, and occlusion occurred after 1 month. Stenoses associated with dialysis shunts were relieved in 2 other patients. Two malignant and one benign inferior vena cava stenoses were relieved either until death, or in the benign case, for 30 months. One malignant subclavian vein obstruction occluded after 24 h due to stent misplacement and another with extrinsic mediastinal compression remained patent until death, extensive thrombus having been lysed prior to stent placement. The results of this short series suggest that the Gianturco self-expanding stent in the vena cava and large veins is easy and safe to place, and in most cases produces almost immediate palliation of the distressing effects of venous obstruction, often in a preterminal and inoperable patient.

Use of the Wallstent in the venous system including hemodialysis-related stenoses

Eighteen patients with a total of 23 venous stenoses or occlusions were treated with the Wallstent. In 5 patients treated for malignant stenosis there was one primary failure due to insufficient stent expansion. The other 4 patients showed rapid relief of their inflow obstruction, all remaining asymptomatic despite later stent occlusion in 1 patient. Four patients were treated for benign postoperative stenoses of the iliac or femoral vein. All stents remained patent for a period of 6 weeks-58 months. Nine patients were treated for one or multiple stenoses along the venous outflow tract of hemodialysis fistulas. Of 14 lesions that were eventually stented, 12 are still patent after 3-27 months (mean 19). However, 10 secondary interventions (eight percutaneous transluminal angioplasty (PTA), two stents) and three additional stent procedures for new lesions were necessary. Although our experience is limited, we believe that patients with tumor compression or postoperative strictures of large veins benefit from treatment with stents. Stenting of venous outflow stenoses in hemodialysis fistulas can significantly prolong stent function, however, PTA should always be the first treatment of choice.

Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.