Clinical Radiology(1992)
45, 278-280
Case Report: Superior Vena Cava Obstruction Complicated by Central Venous Thrombosis- Treatment With Thrombolysis and Gianturco-Z Stents R . D_ E D W A R D S ,
J_ C A S S I D Y *
and A. TAYLOR
Department of Radiology and *Beatson Oncology Centre, Western Infirmary, Glasgow Expandable wire stents can provide effective palliation of superior vena cava obstruction (SVCO). We describe a case of S V C O unresponsive to radiotherapy and chemotherapy, which was complicated by extensive central venous thrombosis. Successful thrombolysis occurred with low-dose streptokinase allowing subsequent stent placement. Edwards, R.D., Cassidy, J. & T a y l o r , A . (1992)_ Clinical Radiology 4 5 , 2 7 8 2 8 0 . C a s e R e p o r t : ' S u p e r i o r V e n a C a v a Obstruction Complicated by Central Venous Thrombosis - Treatment With Thrombolysis and Gianturco-Z Stents
CASE
REPORT
A 62-year-old m a n presented with a 3 week history of facial oedema and mild exertional dyspnoea. He had smoked 30 cigarettes daily for many ycars. Clinical examination showed swelling of the head and neck, periorbital oedema and distended anterior chest wall veins. Breath sounds were reduced in the left mid zone and 6 cm hepatomegaly was present. A chest radiograph showed two left mid zone opacities and superior mediastmal widening. Metastatic liver disease was confirmed by ultrasound. Bronchoscopy was normal but the histology of a hard, fixed right paratraehcal node biopsied at mediastinoscopy revealcd poorly dlfl'erentiated large-cell carcinoma of the bronchus. The patient received palliative radiotherapy to the mediastinum (2000 cGy in five fractions) with no clinical improvement and thereafter, chemotherapy with Mitomycin C, Ifosfanaide and Cisplatin was given via an arm vein. The following day, increasing facial swelling was noted and this persisted until his next admission 3 weeks later. Digital subtraction venography, at this time, showed occlusion of the right innominatc vein with sharp 'cut-off" consistent with thrombus (Fig. 1). The left innominatc vein was occluded and clot was also present in the left subclavian vein (Fig. 2). Delayed images showed mediastinal collaterals but no opacification of the superior vena cava (SVC).
Fig. 1 - Right subclavian venogram showing thrombotic occlusion of the right innominate vein. Correspondence to: Dr R. D. Edwards, Department of Radiology, Western Infirmary, D u m b a r t o n Road, Glasgow GI 1 6NT.
In view of the lack of other therapeutic alternatives, a trial of thrombolysis was considered appropriate. A 5 F catheter was placed 2 cm into the right innominate vein thrombus, and another was sited in the left subclavian vein just proximal to the intraluminal clot. Streptokinase was infused at a rate of 5000 U / h via each catheter. The left subclavian catheter was advanced into the innominate vein the next day following partial clot lysis. Streptokinase was stopped after 40 h following a prolonged epistaxis. This complication was treated conscrva lively. Repeat venography showed complete clot lysis with patency of both innominate veins, and revealed a tight stenosis of the mid SVC (Fig. 3). Following right femoral venous catheterization, the SVC stenosis was dilatated with a 15 m m balloon catheter to a pressure of 800 kPa. Despite three dilatations, the balloon could only be inflated to 75% of its m a x i m u m diameter at the site of thc stenosis. Following angioplasty, a check venogram showed only a minimal increase in luminal diameter. The uncompressed caval lumen measured 19 m m and, in view of the nature of the stricture, a 30 × 50 m m selfexpanding Gianturco-Z stent (Win Cook Ltd) was chosen to provide a greater expansile force. Oversizing of the stent diameter by 25 50% is recommended in the case of a tough or fibrotic stenosis. The 50 m m double stent is preferable to the 25 m m single stcnt because of greater positional stability during deployment.
Fig. 2 - L e f t subclavian venogram showing occlusion of the left innominate vein and non-occlusive thrombus in the left subclavian vein (arrowheads).
SVC OBSTRUCTION WITH CENTRAL VENOUS THROMBOSIS Following stent placement, satisfactory improvement in the luminal diameter was achieved with fi'ee flow of contrast into the right atrium (Fig. 4). Heparin (5000 U) was given during the procedure but the patient received no further anti-coagulants. The symptoms of SVC obstruction resolved within 24 h and did not recur. The patient died 51 days later duc to metastatic disease. Post-mortem examination showed no evidence of stent migration, and the SVC and innominate veins remained patent. A small amount of adherent thrombus covered the struts but the stent was not incorporated into the caval wall. The SVC was encased by a combination of dense post-radiation fibrosis and metastatic tumour. Metastases were also present in both lungs, liver, adrenals, pelvis and spine. There was no evidence of pulmonary thromboembolism.
DISCUSSION Bronchial c a r c i n o m a is the c o m m o n e s t cause o f SVC o b s t r u c t i o n a n d is usually effectively treated by r a d i o t h e r a p y ( D a v e n p o r t et al., 1978). R e c u r r e n t SVC obstruc-
Fig. 3 Cavagram after 40 h oflysis shows patency of both innominate veins and underlying SVC stenosis (arrowhead).
279
tion occurs in 10-19% o f cases, and is commonlY due to r e c u r r e n t turnout, r a d i a t i o n fibrosis or s u p e r i m p o s e d t h r o m b o s i s (Perez et al., 1978)_ T h e use o f p c r c u t a n e o u s t r a n s l u m i n a l a n g i o p l a s t y ( P T A ) in the t r e a t m e n t o f S V C O has been r e p o r t e d (Sherry et al., 1986) b u t its role is p r o b a b l y limited to benign disease_ P T A o f benign central v e n o u s stenoses, in p a t i e n t s with ipsilateral h a e m o d i a l y s i s shunts, has been e m p l o y e d in larger series b u t the r e c u r r e n t stenosis rate is high, with r e p o r t e d 1 y e a r p a t e n c y rates o f 35 % ( G l a n z e t al_, 1988). Initial e x p e r i m e n t a l w o r k with self-expanding G i a n t u r c o - Z stents ( W r i g h t et al., 1985), led to successful clinical use in the t r e a t m e n t o f S V C O ( C h a r n s a n g a v e j et al., 1986; R o s c h et al., 1987). Stent p l a c e m e n t is c o n t r a i n d i c a t e d in the presence o f central venous t h r o m b o s i s b u t has been r e p o r t e d following successful t h r o m b o l y s i s with U r o k i n a s e ( P u t n a m et al., 1988). A l t h o u g h U r o k i n a s e has a n u m b e r o f clinical a n d p h a r m a c o l o g i c a l a d v a n t a g e s (Van B r e d a et al., 1987), S t r e p t o k i n a s e remains in c o m m o n use in the U K due to its relatively low cost. In this case, r a d i o t h e r a p y was ineffective in relieving S V C O and the r a p i d d e t e r i o r a t i o n in s y m p t o m s following c h e m o t h e r a p y suggests that SVC t h r o m b o s i s occurred as a rcsult of, or was e x a c e r b a t e d by, c y t o t o x i c drugs infused via the o b s t r u c t e d central veins. V e n o g r a p h y 3 weeks after c h e m o t h e r a p y confirmed central venous t h r o m b o s i s but despite the likely age o f the clot c o m p l e t e lysis o c c u r r e d after a 40 h infusion o f l o w - d o s e Streptokinase. R e p o r t s o f l o w - d o s e t h r o m b o l y s i s in central venous t h r o m b o s i s are limited to small series, b u t a recanalization rate o f 70% can be achieved in acute axillarysubclavian vein t h r o m b o s i s ( H u e y et al., 1987). Results o f lytic t h e r a p y in chronic venous t h r o m b o s i s are likely to be p o o r e r , but the success rate has n o t been d e t e r m i n e d in a similar study. L o w - d o s e t h r o m b o l y s i s can be r e w a r d i n g in chronic arterial t h r o m b o s i s a n d a lysis rate o f 57% has been r e p o r t e d in patients with occlusions o f 3 weeks d u r a t i o n or m o r e (Katzen, t988). A t h e r a p e u t i c trial o f lytic t h e r a p y should therefore be c o n s i d e r e d in patients with central venous t h r o m b o s i s , p r o v i d i n g there are no medical c o n t r a i n d i c a t i o n s , as the clinical benefits m a y outweigh the p o t e n t i a l risks. Bleeding c o m p l i c a t i o n s in this case were minor, a l t h o u g h m o r b i d i t y rises r a p i d l y with p r o l o n g e d lysis times. N e w e r m e t h o d s o f d r u g a d m i n i s t r a t i o n , including p u l s e d - s p r a y injection o f t h r o m b o l y t i c agents, have resulted in a significant reduction in lysis times (Valji et al., 1991), a n d m a y have a place in the t r e a t m e n t o f central venous thrombosis. G i a n t u r c o - Z stents offer p r o l o n g e d p a l l i a t i o n o f sympt o m s a n d should be c o n s i d e r e d in cases o f recurrent or r e f r a c t o r y SVCO_ Extensive central venous t h r o m b o s i s m a y be treated successfully with l o w - d o s e Streptokinase, allowing subsequent stent placement.
REFERENCES
Fig. 4 Cavagram following insertion of Gianturco-Z stent (arrowhead).
Charnsangavej, C, Carrasco, CH, Wallace, S, Wright, KC, Ogawa, K, Richli, W e t al. (1986). Stenosis of the vena cava: preliminary assessment of treatment with expandable metallic stents. Radiology, 16l, 295 298.
280
CLINICAL RADIOLOGY
Davenport, D, Ferree, C, Blake, D & Raben, M (1978). Radiation therapy m the treatment of superior vena caval obstruction. Cancer, 42, 2600 2603. Glanz, S, Gordon, DH, Lipkowitz, GS, Butt, KMH, Hong, J & Sclaf~ni, SJA (1988). Axillary and subclavian stenosis: percutaneous angioplasty. Radiology, 168, 371 373. Huey, H, Morris, DC, Nichols, DM, Connell, DG & Fry, PD (1987). Low-dose Streptokinase thrombolysis of axillary-subclavian vein thrombosis. Cardiovascular and hlterventional Radiology, 10, 92 95. Katzen, BT (1988). Techniques and results of "low-dose" infusion. Cardiovascular and Interventional Radiology, 11, $41-$47. Perez, CA, Presant, CA & Van Amburg III, AL (1978). Management of superior vena cava syndrome. Seminars in Oncology, 5, 123-134. Putnam, 1S, Uchida, BT, Antonovic, R, & Rosch, J (1988). Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wire stents. Rad:ology, 167, 727 728.
Rosch, J, Bedell, JE, Putnam, JS, Antonovic, R & Uchida, BT (1987). Gianturco expandable wire stents in the treatment of superior vena cava syndrome recurring after maximum-tolerance radiation. Cancer, 60, 1243 1246. Sherry, CS, Diamond, NG, Meyers, TP &, Martin, RL (1986). Successful treatment of superior vena cava syndrome by venous angioplasty. American Journal of Roentgenology, 147, 834 835. Valji, K, Bookstein, JJ, Roberts, AC & Davis, GB (1991). Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: early and late clinical results. Radiology, 178, 243 247. Van Breda, A, Katzen, BT &, Deutsch, AS (1987). Urokinase versus Streptokinase in local thrombolysis. Radiology, 165, 109 111. Wright, KC, Wallace, S, Charnsangavej, C, Carrasco, CH & Gianturco, C (1985). Percutaneous endovascular stents: an experimental evaluation. Radiology, 156, 69 72.
45, 278-280
Case Report: Superior Vena Cava Obstruction Complicated by Central Venous Thrombosis- Treatment With Thrombolysis and Gianturco-Z Stents R . D_ E D W A R D S ,
J_ C A S S I D Y *
and A. TAYLOR
Department of Radiology and *Beatson Oncology Centre, Western Infirmary, Glasgow Expandable wire stents can provide effective palliation of superior vena cava obstruction (SVCO). We describe a case of S V C O unresponsive to radiotherapy and chemotherapy, which was complicated by extensive central venous thrombosis. Successful thrombolysis occurred with low-dose streptokinase allowing subsequent stent placement. Edwards, R.D., Cassidy, J. & T a y l o r , A . (1992)_ Clinical Radiology 4 5 , 2 7 8 2 8 0 . C a s e R e p o r t : ' S u p e r i o r V e n a C a v a Obstruction Complicated by Central Venous Thrombosis - Treatment With Thrombolysis and Gianturco-Z Stents
CASE
REPORT
A 62-year-old m a n presented with a 3 week history of facial oedema and mild exertional dyspnoea. He had smoked 30 cigarettes daily for many ycars. Clinical examination showed swelling of the head and neck, periorbital oedema and distended anterior chest wall veins. Breath sounds were reduced in the left mid zone and 6 cm hepatomegaly was present. A chest radiograph showed two left mid zone opacities and superior mediastmal widening. Metastatic liver disease was confirmed by ultrasound. Bronchoscopy was normal but the histology of a hard, fixed right paratraehcal node biopsied at mediastinoscopy revealcd poorly dlfl'erentiated large-cell carcinoma of the bronchus. The patient received palliative radiotherapy to the mediastinum (2000 cGy in five fractions) with no clinical improvement and thereafter, chemotherapy with Mitomycin C, Ifosfanaide and Cisplatin was given via an arm vein. The following day, increasing facial swelling was noted and this persisted until his next admission 3 weeks later. Digital subtraction venography, at this time, showed occlusion of the right innominatc vein with sharp 'cut-off" consistent with thrombus (Fig. 1). The left innominatc vein was occluded and clot was also present in the left subclavian vein (Fig. 2). Delayed images showed mediastinal collaterals but no opacification of the superior vena cava (SVC).
Fig. 1 - Right subclavian venogram showing thrombotic occlusion of the right innominate vein. Correspondence to: Dr R. D. Edwards, Department of Radiology, Western Infirmary, D u m b a r t o n Road, Glasgow GI 1 6NT.
In view of the lack of other therapeutic alternatives, a trial of thrombolysis was considered appropriate. A 5 F catheter was placed 2 cm into the right innominate vein thrombus, and another was sited in the left subclavian vein just proximal to the intraluminal clot. Streptokinase was infused at a rate of 5000 U / h via each catheter. The left subclavian catheter was advanced into the innominate vein the next day following partial clot lysis. Streptokinase was stopped after 40 h following a prolonged epistaxis. This complication was treated conscrva lively. Repeat venography showed complete clot lysis with patency of both innominate veins, and revealed a tight stenosis of the mid SVC (Fig. 3). Following right femoral venous catheterization, the SVC stenosis was dilatated with a 15 m m balloon catheter to a pressure of 800 kPa. Despite three dilatations, the balloon could only be inflated to 75% of its m a x i m u m diameter at the site of thc stenosis. Following angioplasty, a check venogram showed only a minimal increase in luminal diameter. The uncompressed caval lumen measured 19 m m and, in view of the nature of the stricture, a 30 × 50 m m selfexpanding Gianturco-Z stent (Win Cook Ltd) was chosen to provide a greater expansile force. Oversizing of the stent diameter by 25 50% is recommended in the case of a tough or fibrotic stenosis. The 50 m m double stent is preferable to the 25 m m single stcnt because of greater positional stability during deployment.
Fig. 2 - L e f t subclavian venogram showing occlusion of the left innominate vein and non-occlusive thrombus in the left subclavian vein (arrowheads).
SVC OBSTRUCTION WITH CENTRAL VENOUS THROMBOSIS Following stent placement, satisfactory improvement in the luminal diameter was achieved with fi'ee flow of contrast into the right atrium (Fig. 4). Heparin (5000 U) was given during the procedure but the patient received no further anti-coagulants. The symptoms of SVC obstruction resolved within 24 h and did not recur. The patient died 51 days later duc to metastatic disease. Post-mortem examination showed no evidence of stent migration, and the SVC and innominate veins remained patent. A small amount of adherent thrombus covered the struts but the stent was not incorporated into the caval wall. The SVC was encased by a combination of dense post-radiation fibrosis and metastatic tumour. Metastases were also present in both lungs, liver, adrenals, pelvis and spine. There was no evidence of pulmonary thromboembolism.
DISCUSSION Bronchial c a r c i n o m a is the c o m m o n e s t cause o f SVC o b s t r u c t i o n a n d is usually effectively treated by r a d i o t h e r a p y ( D a v e n p o r t et al., 1978). R e c u r r e n t SVC obstruc-
Fig. 3 Cavagram after 40 h oflysis shows patency of both innominate veins and underlying SVC stenosis (arrowhead).
279
tion occurs in 10-19% o f cases, and is commonlY due to r e c u r r e n t turnout, r a d i a t i o n fibrosis or s u p e r i m p o s e d t h r o m b o s i s (Perez et al., 1978)_ T h e use o f p c r c u t a n e o u s t r a n s l u m i n a l a n g i o p l a s t y ( P T A ) in the t r e a t m e n t o f S V C O has been r e p o r t e d (Sherry et al., 1986) b u t its role is p r o b a b l y limited to benign disease_ P T A o f benign central v e n o u s stenoses, in p a t i e n t s with ipsilateral h a e m o d i a l y s i s shunts, has been e m p l o y e d in larger series b u t the r e c u r r e n t stenosis rate is high, with r e p o r t e d 1 y e a r p a t e n c y rates o f 35 % ( G l a n z e t al_, 1988). Initial e x p e r i m e n t a l w o r k with self-expanding G i a n t u r c o - Z stents ( W r i g h t et al., 1985), led to successful clinical use in the t r e a t m e n t o f S V C O ( C h a r n s a n g a v e j et al., 1986; R o s c h et al., 1987). Stent p l a c e m e n t is c o n t r a i n d i c a t e d in the presence o f central venous t h r o m b o s i s b u t has been r e p o r t e d following successful t h r o m b o l y s i s with U r o k i n a s e ( P u t n a m et al., 1988). A l t h o u g h U r o k i n a s e has a n u m b e r o f clinical a n d p h a r m a c o l o g i c a l a d v a n t a g e s (Van B r e d a et al., 1987), S t r e p t o k i n a s e remains in c o m m o n use in the U K due to its relatively low cost. In this case, r a d i o t h e r a p y was ineffective in relieving S V C O and the r a p i d d e t e r i o r a t i o n in s y m p t o m s following c h e m o t h e r a p y suggests that SVC t h r o m b o s i s occurred as a rcsult of, or was e x a c e r b a t e d by, c y t o t o x i c drugs infused via the o b s t r u c t e d central veins. V e n o g r a p h y 3 weeks after c h e m o t h e r a p y confirmed central venous t h r o m b o s i s but despite the likely age o f the clot c o m p l e t e lysis o c c u r r e d after a 40 h infusion o f l o w - d o s e Streptokinase. R e p o r t s o f l o w - d o s e t h r o m b o l y s i s in central venous t h r o m b o s i s are limited to small series, b u t a recanalization rate o f 70% can be achieved in acute axillarysubclavian vein t h r o m b o s i s ( H u e y et al., 1987). Results o f lytic t h e r a p y in chronic venous t h r o m b o s i s are likely to be p o o r e r , but the success rate has n o t been d e t e r m i n e d in a similar study. L o w - d o s e t h r o m b o l y s i s can be r e w a r d i n g in chronic arterial t h r o m b o s i s a n d a lysis rate o f 57% has been r e p o r t e d in patients with occlusions o f 3 weeks d u r a t i o n or m o r e (Katzen, t988). A t h e r a p e u t i c trial o f lytic t h e r a p y should therefore be c o n s i d e r e d in patients with central venous t h r o m b o s i s , p r o v i d i n g there are no medical c o n t r a i n d i c a t i o n s , as the clinical benefits m a y outweigh the p o t e n t i a l risks. Bleeding c o m p l i c a t i o n s in this case were minor, a l t h o u g h m o r b i d i t y rises r a p i d l y with p r o l o n g e d lysis times. N e w e r m e t h o d s o f d r u g a d m i n i s t r a t i o n , including p u l s e d - s p r a y injection o f t h r o m b o l y t i c agents, have resulted in a significant reduction in lysis times (Valji et al., 1991), a n d m a y have a place in the t r e a t m e n t o f central venous thrombosis. G i a n t u r c o - Z stents offer p r o l o n g e d p a l l i a t i o n o f sympt o m s a n d should be c o n s i d e r e d in cases o f recurrent or r e f r a c t o r y SVCO_ Extensive central venous t h r o m b o s i s m a y be treated successfully with l o w - d o s e Streptokinase, allowing subsequent stent placement.
REFERENCES
Fig. 4 Cavagram following insertion of Gianturco-Z stent (arrowhead).
Charnsangavej, C, Carrasco, CH, Wallace, S, Wright, KC, Ogawa, K, Richli, W e t al. (1986). Stenosis of the vena cava: preliminary assessment of treatment with expandable metallic stents. Radiology, 16l, 295 298.
280
CLINICAL RADIOLOGY
Davenport, D, Ferree, C, Blake, D & Raben, M (1978). Radiation therapy m the treatment of superior vena caval obstruction. Cancer, 42, 2600 2603. Glanz, S, Gordon, DH, Lipkowitz, GS, Butt, KMH, Hong, J & Sclaf~ni, SJA (1988). Axillary and subclavian stenosis: percutaneous angioplasty. Radiology, 168, 371 373. Huey, H, Morris, DC, Nichols, DM, Connell, DG & Fry, PD (1987). Low-dose Streptokinase thrombolysis of axillary-subclavian vein thrombosis. Cardiovascular and hlterventional Radiology, 10, 92 95. Katzen, BT (1988). Techniques and results of "low-dose" infusion. Cardiovascular and Interventional Radiology, 11, $41-$47. Perez, CA, Presant, CA & Van Amburg III, AL (1978). Management of superior vena cava syndrome. Seminars in Oncology, 5, 123-134. Putnam, 1S, Uchida, BT, Antonovic, R, & Rosch, J (1988). Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wire stents. Rad:ology, 167, 727 728.
Rosch, J, Bedell, JE, Putnam, JS, Antonovic, R & Uchida, BT (1987). Gianturco expandable wire stents in the treatment of superior vena cava syndrome recurring after maximum-tolerance radiation. Cancer, 60, 1243 1246. Sherry, CS, Diamond, NG, Meyers, TP &, Martin, RL (1986). Successful treatment of superior vena cava syndrome by venous angioplasty. American Journal of Roentgenology, 147, 834 835. Valji, K, Bookstein, JJ, Roberts, AC & Davis, GB (1991). Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: early and late clinical results. Radiology, 178, 243 247. Van Breda, A, Katzen, BT &, Deutsch, AS (1987). Urokinase versus Streptokinase in local thrombolysis. Radiology, 165, 109 111. Wright, KC, Wallace, S, Charnsangavej, C, Carrasco, CH & Gianturco, C (1985). Percutaneous endovascular stents: an experimental evaluation. Radiology, 156, 69 72.
