Card)ovasc lntervent Radiol (1992) 15 319-327

CardioVascular andInterventional

Radiology

Springer-Verlag New York Inc. 1992

Vascular Applications" Veins Gianturco-R6sch Expandable Z-Stents in the Treatment of Superior Vena Cava Syndrome J o s e f R 6 s c h , B a r r y T. U c h i d a , L e e D. H a l l , R u z a A n t o n o v i c , B r y a n D. P e t e r s e n , K r a s s i I v a n c e v , R o b e r t E. B a r t o n , a n d F r e d e r i c k S. K e l l e r Charles Dotter Inshtute for Interventional Therapy, Oregon Health Sciences University and Veterans Administration Medlcal Center, Portland, Oregon, USA

Abstract. G i a n t u r c o - R 6 s c h e x p a n d a b l e Z - s t e n t s w e r e u s e d in 22 p a t i e n t s with s u p e r i o r v e n a c a v a s y n d r o m e ( S V C S ) . S t e n t s w e r e p l a c e d in all p a t i e n t s in the S V C a n d in 17 p a t i e n t s , a l s o into the i n n o m i n a t e v e i n s . S t e n t p l a c e m e n t r e s u l t e d in c o m p l e t e r e l i e f o f s y m p t o m s in all p a t i e n t s . T w e n t y - o n e pat i e n t s h a d no S V C S r e c u r r e n c e f r o m 1 to 16 m o n t h s , to t h e i r d e a t h , o r to t h e p r e s e n t time. S V C S r e c u r r e d o n l y in 1 p a t i e n t 9 m o n t h s a f t e r s t e n t p l a c e m e n t d u e to t u m o r i n g r o w t h a n d s e c o n d a r y t h r o m b o s i s . B a s e d on ours and on other reported experiences, expanda b l e m e t a l l i c s t e n t s a r e e f f e c t i v e d e v i c e s for t r e a t m e n t o f t h e S V C S w h i c h is difficult to m a n a g e b y other means.

Material and M e t h o d s Of the 22 patients. 16 were men and 6 were women; their ages ranged from 28 to 68 years (median, 56 years). In 2 patients. SVCS was caused by a benign process, postradiation fibrosis and mediastimtls, respectively. Of the 20 patients with mahgnant etiology of SVCS. the SVC obstruction was caused by mediastinal extension of lung carcinoma in 14 patients and mediastmal metastases of abdominal tumors in 6 pauents. AI) patmnts had advanced SVCS with face, neck. and arm swelhng and venous engorgement. Twelve p.~I,,.'u'~~;.:0 .,i.,-'i,C'c..Htfaclal cyanosis. 5 had hoarseness, and 7 ,o~:.p:.,...cd ,,' ,c:c,c headaches. In 12 patients, SVCS symptoms developed from 5 months to 4 years following maximum radmtion of thmr tumors; in I patient the SVCS occurred during radmtion of his hmg carcinoma.

Key words: Superior vena cava syndrome-- Venous obstruction--Lung carcinoma--Expandable metallic s t e n t - - G i a n t u r c o - R O s c h Z - s t e n t ~-=

Treatment of the superior vena cava syndrome ( S V C S ) is difficult, p a r t i c u l a r l y in p a t i e n t s with o b structions caused by malignant tumors and/or postradiation fibrosis. Patients are usually treated medically with minimal relief of their severe congestive symptoms. After our successful treatment of SVCS with modified Gianturco self-expandable Z-stents ( G i a n t u r c o - R 6 s c h Z - s t e n t s ) (Fig. 1) in 2 p a t i e n t s [1], w e u s e d t h e m in a n o t h e r 20 p a t i e n t s a n d s u m m a r i z e our experience.

Address reprint requests to: Josef Rosch, M.D., Charles Dotter

Institute for Interventional Therapy, Oregon Health Sciences University, L342, 3181 SW Sam Jackson Park Road, Portland, Oregon 97201, USA

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Fig. 1. The Gtanturco-R6sch self expandable Z-stents hand made m our research laboratory. A A double-body 15-ram diameter stent without barbs. B A three-body 18-ram diameter stent w~th barbs at its upper body. C A four-body 18-mm diameter stent with barbs at its second lower body.

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Fig. 2. A 58-year-old w o m a n with severe superior vena c a v a s y n d r o m e s e c o n d a r y to postradiation fibrosis. After stent placement she was a s y m p t o m a t l c for I l m o n t h s unhl her death of a stroke. A Initial superior v e n a c a v a g r a m reveals two concentric s t e n o s e s and retrograde filling o f collaterals B Superior vena c a v a g r a m immediately after p l a c e m e n t of a double-body stent with a skirt s h o w s good flow through the stent which e x p a n d e d to a b o u t 60% of its d i a m e t e r . C Superior v e n a c a v a g r a m 2 m o u t h s after stent p l a c e m e n t reveals further e x p a n s m n o f the stent and improved flow.

Control v e n o g r a m s in 2 patients with b e m g n obstructions exhibited tight, concentric, s m o o t h l y outlined s t e n o s e s of the SVC (Fig. 2). With malignant lesions, v e n o g r a p h y revealed a wide range o f findings from irregular s t e n o s e s s e c o n d a r y to c o m p r e s sion, a n ~ o r direct i n v a s i o n o f the t u m o r ~n -- !3) to complete SVC occlusion (n = 7) (Figs. 3-7). In 17 patients the obstructive p r o c e s s e x t e n d e d into the r e n o m i n a t e vein(s). T h e right innominate vein was involved t o g e t h e r with the SVC in 9 patients and in 1 o f t h e m the stenosis e x t e n d e d also on the subclavmn vein. T h e left innominate vein w a s involved in 3 patients and both i n n o m i n a t e veins in 5 patients, usually in thmr proximal portions. In 7 patients with c o m p l e t e S V C occlusion and 5 patients with significant thrombi in the S V C or its b r a n c h e s above the obstruction, selective infusion o f u r o k i n a s e ( 12-72 h) was u s e d to achieve c o m p l e t e t h r o m b o l y s i s prior to stent p l a c e m e n t (Figs. 4, 5, 7). We u s e d the G i a n t u r c o - R 0 s c h self-expandable Z-stents m a d e in o u r r e s e a r c h laboratory f r o m stainless steel wire 0.014-0.016 inches in diameter (Fig. 1). T h m r legs were c o n n e c t e d with m o n o filament line to control their e x p a n s i o n to a diameter of 1 . 5 - l . 8

cm. T h e single bod~ >tent~ were 2 - 3 c m long. Depending on the length of the o b s t r u c t i v e lesion, two to five single body >tents were c o n n e c t e d together with a m o n o l i l a m e n t hne to form a stent 5 - 1 0 cm long. T h e SVC s t e m s in the first of 10 p a t m n t s had on thmr distal e n d s a t.5 cm long wire skirt containing small hooks to prevent stent m i g r a n o n . T w o stents had a skwt, but w~thout hooks, also on their proximal e n d s , The SVC stents m the latter 12 patient~ did not ha'~e skwts at their e n d s but had two barbs at one of t h m r bodies. T h e barbs were a t t a c h e d to the body placed in the c e n t e r o f stenos~s. The stents placed m the i n n o m i n a t e veins above the SVC stents did not h a v e skirts or barbs. The institutional H u m a n R e s e a r c h C o m m i t t e e gave approval for stents to be used on a c o m p a s s i o n a t e bas~s and the p a u e n t s signed an informed c o n s e n t for the procedure. T h e right transfemoral a p p r o a c h was u s e d in all patients for stent p l a c e m e n t into the SVC, right i n n o m i n a t e vein, and in 3 patients, into the left renominate vein. In 5 patients, the left i n n o m i n a t e stent was placed by the left transjugular a p p r o a c h (Fig. 6). A 12-ram balloon c a t h e t e r w a s introduced first a n d inflated inside the o b s t r u c t e d region. Th~s was done m o r e for delineation of the e x t e n t of the o b s t r u c t i o n rather than for dilatmn, b e c a u s e in the majority of patients the o b s t r u c t i o n relapsed after balloon deflation. T h e extent of the lesion was t h e n m a r k e d for exact stent positLoning. A 12-14 F r e n c h Teflon s h e a t h with an introducing catheter inside was then e x c h a n g e d for the balloon catheter. T h e stent was then loaded o v e r a gmdewire, i n t r o d u c e d into the s h e a t h , and p u s h e d to its end. Still reside the s h e a t h , it was carefully posttioned j u s t a b o v e the m a r k e d u p p e r end o f the stenotic lesion. T h e stent was then deployed by withdrawing the s h e a t h while holding the stent in positlon with a p u s h e r . E x t r u d e d from the s h e a t h , the stent e x p a n d e d and dilated the n a r r o w e d v e n o u s lu-

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men. When using several stents, the more distal stent was placed first, followed by more proximal stent(s). The obsfructive lesions were often long and complex and required placement of multiple body stents or stent combinations for expansion of the entire narrowed area(st. A double-body stent was sufficient in only 4 patients. The others received three to five body stents or stents

Fig. 3. A 64-year-old man with severe superior vena cava syndrome secondary to squamous celt carcinoma extending into the mediastinum. The patient was already treated by maximum dose radiation. After stent placement he was asymptomatic for 11 months until his death due to tumor metastases. A & B Imtial venograms show severe obstructton of the superior vena cava secondary to direct tumor ingrowth9 C Superior vena cavagram ~mmediately after placement of a double-body stent with skirts shows good stent expansion and excellent superior vena cava patency. D Superior vena cavagram 2 months after stent placement demonstrates further stent expansion. Filling defects at the stent outhne could be due to tumor ingrowth and/or intimal hyperplasia.

in combination, with I patient receiving one four-body and two double-body stents. The majority of the stents usually expanded only to 10-12 ram; however, they continued to expand in the next few days. In 1 patient with a focal concentnc narrowing, a tight stenosis milked the stent cranially. A ~econd stent placed partially into the first one satisfactorily expanded the stenos~s. Localiza-

322

J Rosch ct al.: Superior Vena Cava Syndrome

Fig. 4. A 68-year-old man with severe superior vena cava syndrome due to bronchogenic carcinoma. He became symptomatic during his radiation treatment. After stent placement he remained asymptomatic for 6 months until his death. A, Initial venogram reveals occlusion of the superior vena cava, thrombus in its main tributaries, and filling of collaterals. B Follow-up venogram after 48 h of local infusion of urokinase shows lysis of thrombi and severe stenosis of the distal portion of the superior vena t a r a . C Superior vena cavagram immediately after placement of a double-body stent with a skirt shows good expansion of the stent and excellent flow m the superior vena cava. D Superior vena cavagram 2 months after stem placement reveals further expansion of the stent and improved flow. tion of the stent placement is detailed in Table 1. In all patients, a follow-up venogram was done after stent placement. Patients were heparimzed during the procedure and for 3-4 days afterwards, then they were switched to coumadin The anticoagulation therapy continued for 2 or 3 months in patient,~ with benign strictures and indefinitely in patients with malignant tumorous obstructions,

All patients were followed clinically at 1 month intervals (at teastl. A chest radiograph was done I month after stent placement to evaluate stent position and diameter, Follow-up venograms were performed in 4 asymptomatic patients 2 months after stent placement to evaluate the anatomy of the stented vessel. One of these patients also had a follow-up venogram 9 months after stent placement at the time of recurrent symptoms.

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Fig. 5. A 62-year-old man ~i~h severe ~uperior vena cava ayndrome secondary to mediastmal metastases of a colon carcinoma. The patient remained asymptomatic for 9 months when his syndrome recurred due to tumor ingrowth mto the stent and secondary thrombosis. He died 1 month later. A Superior vena cavagram reveals severe focal stenosis with large thrombl m the superior vena cava, and left renominate vein B Follow-up venogram after 24 h of local infusion of urokinase reveals ly~ls of all thromN and persistent ~evere stenoslb of the superior vena cava. C Follow-up cavagram 2 months after placement of a doublebody stent shows complete ~tent expansion and excellent flow tn the superior vena cava. D Superior vena cavagram 9 month~ after ~tent placement demonstrates a large defect at the po.~tenor wall of the stem which intravascular b~op~y proved to be ingrowing tumor.

Results

Stent placement proceeded smoothly and without c o m p l i c a t i o n in 21 p a t i e n t s . In 1 p a t i e n t with s i m u l t a n e o u s p l a c e m e n t o f s t e n t s in the S V C a n d b o t h innominate veins, a prolonged procedure was complic a t e d by t h r o m b o s i s o f the i n n o m i n a t e vein s t e n t s , e v e n with t h e p a t i e n t f u l l y h e p a r i n i z e d . T h e p a t i e n t r e c e i v e d s e l e c t i v e u r o k i n a s e i n f u s i o n f o r 6 h, w h i c h l y s e d the c l o t s a n d o p e n e d a p a s s a g e w a y t h r o u g h t h e s t e n t . A f e w p a t i e n t s felt c h e s t p a i n d u r i n g b a l l o o n inflation o f t h e s t e n o t i c r e g i o n a n d a f t e r s t e n t p l a c e ment. The pain, however, disappeared within a few minutes and did not recur. In all p a t i e n t s , s t e n t p l a c e m e n t r e s u l t e d in r e l i e f o f t h e i r s y m p t o m s o f S V C S . P a t i e n t s with a c y a n o t i c

Table l. Localizatmn of Stent Placement in 22 PaUents SVC-superior vena cava. Rl-right innommate veto, LI-left innominate vein. RSCL-nght subclavian veto Stent placement

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SVC SVC SVC SVC SVC

5 8 1 3 5

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RI R1 + RSCL LI RI + LI

f a c e u s u a l l y r e t u r n e d to n o r m a l c o m p l e x i o n s h o r t l y a f t e r s t e n t p l a c e m e n t , a n d facial e d e m a a n d h e a d aches regressed by the next day. Truncal and arm e d e m a r e s o l v e d in 2 - 3 d a y s . H o a r s e n e s s p e r s i s t e d . O n I m o n t h f o l l o w - u p c h e s t r a d i o g r a p h s , all s t e n t s r e m a i n e d in p l a c e a n d f u r t h e r e x p a n d e d ano t h e r 2 - 4 m m , a l m o s t to t h e i r full d i a m e t e r . F o l l o w up v e n o g r a m s 2 m o n t h s a f t e r s t e n t p l a c e m e n t s h o w e d e x c e l l e n t p a t e n c y in all 4 p a t i e n t s s t u d i e d (Figs. 2-5). In 1 patient with postradiation fibrosis, the outline of the stent lumen was smooth without i n t i m a l h y p e r p l a s i a (Fig. 2). In 2 p a t i e n t s w i t h malign a n t l e s i o n s , small filling d e f e c t s w e r e s e e n inside the s t e n t , w h i c h w e a t t r i b u t e d to t u m o r i n g r o w t h or i n t i m a l h y p e r p l a s i a {Fig. 3). T h e p a t i e n t w i t h S V C S recurrence 9 months after stent placement, which d e v e l o p e d s h o r t l y a f t e r he d i s c o n t i n u e d c o u m a d i n t r e a t m e n t , s h o w e d c o m p l e t e t h r o m b o s i s o f the stented SVC and both proximal innominate veins. After local urokinase infusion dissolved the thromb u s , a v e n o g r a m d e m o n s t r a t e d g r o s s filling d e f e c t s

324

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