Tough Calls: Case 7

Superior Vena Cava Syndrome 

Imagine how you would work through each case. What equipment would you select and what would you do first? After having a go at it, see what our panel would do in the same situation. This exercise highlights the many possible approaches to a difficult problem. By seeing what others would do after thinking it through yourself, you will gain an understanding of the spectrum of approaches to a problem. 

History 

 

33 year old lady 

- Histoplasmosis in 2009. Subsequently treated with antifungal. Resultant fibrosing mediastinitis 

- In 2017 she had a right upper extremity DVT with swelling of the arms and face and engorgement of the veins. 

How would you treat this lesion? 

Upper venous angiograms:

Expert Approaches

Hover over an experts image to view their approach.

Expert Approaches

Hover over an experts image to view their approach.

  • Treat SVC/INNV stenosis first with bare metal stent (have covered stent available if needed for vascular injury)

  • Once INNV decompressed, redo RIJ picture and check pressure to determine maturity of collaterals to LIJ/INNV

  • If vein remains hypertensive without adequate collateralization, would explore both ends of atretic lesion for beak and recanalize with CTO wire, transseptal needle, RF, etc

Dr. Ryan Callahan
MD, FSCAI
 

Boston Children's Hospital

Division of Invasive Cardiology

Assistant Professor of Pediatrics, Harvard Medical School 

  • Additional imaging required includes right arm venography to assess right subclavian venous return. There is potentially an opportunity to engage from femoral access into the occluded stump of the SVC(strongly encourage biplane angiography and intervention guidance).From there attempt recanalization of the SVC to the RIJV/RSCV if possible. If successful, then start with very small balloons to angioplasty the veins (high pressure and cutting balloons likely required) with ultimate goal of balloon expandable stent implantation(possible kissing stents or alternatively open cell superiorly into theRIJV and through the side cells into the RSCV with stenting there if possible). This is very extensive and may not be possible however

Dr. Matt Crystal
MD, FACC, FSCAI

New York-Presbyterian & Morgan Stanley Children's Hospital

Assistant Professor of Pediatrics, Columbia University Medical Centre
Associate Director, Pediatric Cardiac Catheterization Cardiology

  • Cross over 0.035 wire - Trial gentle ballooning to 5 mm to ensure
    compliance of vein

  • Depending on size use Medtronic Valiant covered stent – both self
    expanding – deployed from normal to normal segment.

  • Balloon expand stent ~3 mm smaller than subclavian vein reference

Dr. Harsimran SIngh
MD, MSc
 

Director, Adult Congenital Heart Disease,

Director, Cardiovascular Disease Fellowship, Weill Cornell Medicine

  • Initial approach with long sheath through lesion from Femoral V. over exchange length 0.035” guidewire

    • I would not try to “bridge” the gap from RIJ to lower SVC

    • *Distance between the superior right IJ and innom/SVC is quite long; right IJ drains to the left innominate system, hopefully relieving the SVC stenosis will provide relief of systemic venous obstructionSx

  • Plan placement of covered stent (i.e. CCPS) through entire length of stenosis

    • Post dilation with high-pressure Atlas balloon to expand to the diameter of the proximal innominate vein; watch for recoil; add’l bare metal if needed inside

  • Monitor carefully post-procedure for re-stenosis

  • Have you also evaluated all the pulmonary veins in this case of fibrosing mediastinitis?

Dr. Allison Calbalka
MD, FSCAI
 

Professor of Pediatrics, Mayo Clinic College of Medicine

Consultant, Pediatric Cardiology 

Director, Congenital Cardiac Laboratory

Mayo Clinic, Rochester, Minnesota

  • I would primarily stent it and use covered stent to prevent intra-tyne hyperplasia.

Dr. Zahid Amin
MD, FSCAI, FAHA, FAAP

William B. Strong Chair and Professor and Section Chief

Division of Pediatric Cardiology 
Congenital and Structural Heart Disease
Children’s Hospital of Georgia, Augusta University