Endovascular treatment of superior vena cava syndrome does not preclude continued use of indwelling hemodialysis and chemotherapy lines

Abstract

Obstruction of the Super Vena Cava (SVC) can result in symptoms, such as facial plethora and swelling, and be due to a variety of underlying causes besides lung malignancies, the rates of which have changed over time; the underlying etiology is used to determine the best management strategy. This case report aims to discuss the role of etiology in determining the best initial treatment for SVC syndrome (SVCS) and outlines the unique management for a patient that represents the changing demographics of SVCS causes. A 73-year-old male with end-stage renal disease and metastatic carcinoma of the colon presented with swelling of the jaw, neck, and tongue. Computed tomography (CT) scan showed chronic thrombosis of the SVC and bilateral brachiocephalic veins. He had been receiving hemodialysis and chemotherapy through central venous catheters (CVCs) that traversed the SVC and terminated in the right atrium. Treatment involved double-barrel stent reconstruction of the SVC with a snare technique to temporarily reposition the chemotherapy port catheter and exchange of the hemodialysis catheter. After this single procedure, he experienced relief of symptoms without disrupting the use of his CVCs for further hemodialysis or chemotherapy appointments. For cases of SVCS due to underlying lung malignancies, which has been and remains the most common cause, endovascular stenting is reserved as a palliative measure when treatment of a refractory malignancy fails to resolve the obstruction and for when symptoms are severe because most cases are not life-threatening. However, increased use of CVCs has caused a rise in SVCS due to thrombosis, for which stenting is the first-line treatment. Of the few previously published case reports that depict using a snare technique to temporarily reposition a CVC, they all describe cases due to lung malignancies. Outlining this case presentation can increase awareness of thrombotic stenosis as an increasingly common cause of SVCS, which may occur in patients with a broader range of underlying conditions, ages, and life expectancies and require a wider array of physicians to be knowledgeable of management strategies. Furthermore, detailing this unique technique can provide therapeutic alternatives that show how endovascular interventions do not disrupt interdisciplinary treatment plans or preclude continued use of CVCs. While stenting technology has improved dramatically since its inception, follow-up on stent patency will help determine if expanding treatment for lower acuity cases is beneficial. Endovascular stenting is the treatment of choice for thrombotic causes of SVCS, which is becoming more common due to the increased use of CVCs. Techniques to temporarily reposition CVCs intra-procedurally allow for limited disruption in multidisciplinary treatment plans for patients with complex underlying conditions.