Interactive Cardiovascular and Thoracic Surgery 2:355-357(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Restenosis of superior vena cava after treatment using a self-expanding metallic stent in a patient with idiopathic fibrosing mediastinitis
Keisuke Eguchia,*,
Koichi Kobayashia,
Ichiro Hasegawab and
Seishi Nakatsukab
a Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
b Department of Radiology, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
* Corresponding author. Tel.: +81-3-5363-3806; fax: +81-3-5363-3499
egukei{at}aol.com
Received November 29, 2002;
received in revised form February 25, 2003;
accepted April 1, 2003
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Abstract
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The use of a self-expanding metallic stent (SEMS) for the treatment of superior vena cava (SVC) syndrome arising from non-neoplastic mediastinal disease is controversial, and data on long-term clinical observations for such have not yet been accumulated. We report a case of fibrosing mediastinitis with an obstruction of the SVC 30 months after the insertion of an SEMS. The patient had a headache and temporal facial swelling when the obstruction occurred, but these symptoms disappeared within 1 month. No further treatment was required in this case.
Key Words: Self-expanding metallic stent; Balloon angioplasty; Superior vena cava syndrome; Fibrosing mediastinitis; Non-neoplastic etiology; Restenosis of superior vena cava Abbreviations: CT, computed tomographic (scan) • IVDSA, intravenous digital subtraction angiography • SEMS, self-expanding metallic stent • SVC, superior vena cava
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1. Introduction
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Self-expanding metallic stents (SEMSs) enable rapid relief from symptoms in patients with stenosis of the superior vena cava (SVC). For patients with SVC syndrome as a result of advanced mediastinal malignancy and who have short life expectancy, the relief offered by SEMS treatment is of great advantage. SEMSs are also sometimes applied for SVC stenosis of non-neoplastic etiologies. However, the use of intravascular stents in these situations is associated with several potential risks. Whether the use of SEMS Is an acceptable treatment for SVC stenosis with a benign clinical course, therefore remains controversial. We present a case of fibrosing mediastinitis with long-term follow-up observations after SEMS placement.
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2. Case report
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A 62-year-old man was admitted to the Kawasaki Municipal Hospital in Kawasaki City, Japan. He had a headache and edema on the face, neck and right upper extremity, with distention of the jugular and superficial chest veins. A computed tomographic (CT) scan confirmed mediasitinal tissue thickening and severe stenosis of the SVC. A venography showed severe stenosis of the SVC; the diameter of the stenotic portion of the SVC measured 2 mm. A right femoral vein puncture was made, and a guide wire was passed through the SVC (Fig. 1a). The stenotic portion was successfully dilated to 5 mm in diameter using a balloon dilator (4 cm long and 10 mm in diameter) three times. The patient complained of substernal chest pain following the procedure, and symptomatic relief was achieved within 2 days. A video-assisted mediastinal biopsy through the right thoracic cavity was performed, and a histological examination showed inflammatory cell infiltrates and fibrosis in the mediastinal soft tissue surrounding the SVC. No evidence of malignancy, granuloma or microorganism invasion was seen.
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Fig. 1 (a) Venogram shows stenosis of SVC. (b) Venogram of the SVC shows a conduit formed after placing SEMS.
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Balloon dilation of the SVC was repeated a total of three times, and the patient's symptoms disappeared 2–4 months after every procedure. After obtaining informed consent, Gianturco Z-stent was placed into the SVC during the fourth procedure (Fig. 1b). Heparin (4000 units) was administered intravenously prior to these procedures. The patient had an uneventful post-procedure course, and his symptoms improved within a few days.
Warfarin administration was continued for 18 months followed by aspirin administration (81 mg/day). A clinical follow-up consisting of an interview, physical examination, intravenous digital subtraction angiography (IVDSA) and contrast CT scan was performed in the out patient clinic, and the patency of the SVC and absence of symptoms was confirmed.
The patient had been free from any symptoms for 30 months after the stent insertion, but one morning he suddenly noticed facial edema, feeling fullness in his head, and dyspnea on exertion, and was referred to our hospital again. Chest X-ray film revealed a small amount of left pleural effusion. An IVDSA examination showed complete SVC obstruction and development of collateral venous circulation without collapse of the stent (Fig. 2). His symptoms were not as severe as in the first attack and improved spontaneously within 1 month. Except for prominent venous dilation over his chest, the patient remains free from the symptoms of SVC syndrome 11 months after the remission.
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Fig. 2 Venogram of the obstructed SVC with an SEMS in place. Contrast medium was injected from the vein of the left upper extremity. Large collateral venous drainage extending over the internal mammary vein and vertebral vein can be seen.
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3. Discussion
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Strategies for the treatment of SVC syndrome arising from non-neoplastic etiologies are controversial. In most of these cases, conservative treatment should be chosen, with the expectation of natural collateral formation, because these clinical courses are not progressive. The treatment effect of medication, such as steroids and diuretics, is not clarified [1]. Surgical or interventional treatment should be considered for the patients with prolonged and severe symptoms. The patency of surgical bypass treatments for SVC syndrome using composite spiral vein grafts has been documented in the patients more than 10 years after their operation [2]; however, several surgical risks are unavoidable with this treatment method. Treatment with SEMS causes rapid symptomatic relief and is less invasive, but complications such as migration, embolization, or infection of the devices have been documented [3]. Patients with SVC syndrome due to fibrosing mediastinitis generally have a normal life span [4], so a treatment with a long-lasting effect is needed. To our knowledge, most observation periods for the patency of the SVC stenting have been for less than 1 year [3,5].
The first treatment we planned for the patient was to perform balloon angioplasty repeatedly, however continuous relief could not be obtained in the present case. SEMS was employed for the subsequent treatment, while obstruction of the SVC occurred 2 years and 6 months after treatment with an SEMS for fibrosing mediastinitis. The obstruction may have been mainly caused by neoendothelialization, but no additional treatment was needed because of the gradual formation of collateral circulation. Of course, the clinical courses of patients receiving SEMS may vary, and additional surgical procedures may be needed in some cases, however, the placement of an SEMS is not expected to create a major disturbance in subsequent operations. By using SEMS, some patients with severe SVC syndrome as a result of non-malignant diseases may be able to avoid surgical bypass.
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Appendix A.
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ICVTS on-line discussion
Author: Pier Luigi Filosso, Staff Surgeon, University of Torino, Department of Thoracic Surgery, Via Genova, 3, Torino 10126, Italy
Date: 08-Jun-2003 10:24
Message: The use of transthoracic tru-cut biopsy of anterior mediastinal masses has been largely diffused in Europe during the last years, in order to achieve a correct diagnosis avoiding invasive surgical procedures. The real problem is the adequateness of the neoplastic tissue specimens obtained. In our hospital thoracic surgeons and radiologists are directly involved in improving this technique, but our preliminary results are not as encouraging as those reported in this paper, especially in the case of lymphoproliferative disorders. This is probably because of the risk of performing biopsy in necrotic areas within the tumour despite the use of ultrasonographic guide. The use of CT scan guide doesn't seem to improve bioptic results, because, only in a few cases, pathologists are able to differ between the histological subtypes of lymphomas. For this reason patients have to be submitted to a surgical biopsy. In our experience, in case of thymoma, tissues obtained through transthoracic biopsy were adequate to achieve a correct diagnosis, also in case of thymic carcinoma or carcinoid, thanks to the improvement of immunohistochemical stainings.
doi:10.1016/S1569-9293(03)00069-0
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References
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Abstract
1. Introduction