Percutaneous Management of Chronic Central Venous Occlusive Disease

Stenosis or occlusion of the central veins and/or vena cava can cause painful and debilitating symptoms for affected patients. Superior vena cava syndrome (SVCS) can develop acutely or progressively from external compression or intrinsic obstruction. The clinical signs and symptoms result from venous hypertension and reduced blood flow in the superior vena cava (SVC) or central veins emptying into the SVC. Depending on the anatomic location of the narrowing, clinical symptoms, and presentation will vary. Clinical signs include cyanosis, plethora, distention of subcutaneous veins, and edema of the upper extremities, head and neck. Edema may compromise laryngeal or pharyngeal function, causing dyspnea, stridor, cough, hoarseness, and dysphagia.[1] Although there may be symptom overlap with congestive heart failure, a physical examination will usually delineate between the two diagnoses.

The etiology of SVCS varies and can be broadly grouped into benign and malignant causes, with most strictures of the caval system and venous tributaries being malignant.[2] [3] Non–small-cell lung cancer (NSCLC) is the most common malignant cause of SVCS, followed by small-cell lung cancer (SCLC) and non-Hodgkin lymphoma.[4] The most common causes of benign venous stenosis involve the presence of an indwelling intravascular device (i.e., catheters, pacemaker/defibrillators, ports). Arteriovenous fistula related obstruction, mediastinal fibrosis, and prior thoracic external bean radiation therapy are additional benign causes.

Treatment of central venous occlusions depends on the etiology and clinical presentation. The ultimate goal of therapy is to correct the obstruction and alleviate the symptoms. Conservative measures depend on the etiology and include limb elevation, steroids, anticoagulation, chemotherapy and/or radiation therapy, and diuretics.[5] Interventional therapies include surgical bypass and/or endovascular stent placement. Guide wire recanalization and endovascular stenting is a minimally invasive procedure that can be performed on an outpatient basis with standard equipment available in an angiography suite. The procedure below describes the authors approach to treating chronic central venous occlusive disease.

• References

• 1 Lepper PM, Ott SR, Hoppe H , et al. Superior vena cava syndrome in thoracic malignancies. Respir Care 2011; 56 (5) 653-666
• 2 Mauro MA, Murphy K, Thomson KR, Venbrux AC, Zollikofer CL. Image-Guided Interventions. Philadelphia, PA: Saunders Elsevier; 2008: 1055
• 3 Parish JM, Marschke Jr RF, Dines DE, Lee RE. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc 1981; 56 (7) 407-413
• 4 Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85 (1) 37-42
• 5 Wudel Jr LJ, Nesbitt JC. Superior vena cava syndrome. Curr Treat Options Oncol 2001; 2 (1) 77-91