Departmen

CorrespondUniversity ofparth-amin@u

Ann Vasc SurDOI: 10.1016/� Annals of V

Anatomic Bifurcated Reconstruction ofChronic Bilateral InnominateeSuperiorVena Cava Occlusion Using theY-Stenting Technique

Parth Amin, Iowa, Iowa

This article presents the case of a 42-year-old man who presented with superior vena cava(SVC) syndrome due to fibrosing mediastinitis with multiple failed attempts at recanalization.We initially treated him with unilateral sharp needle recanalization of the right innominatevein into the SVC stump followed by stenting. Although his symptoms improved immediately,they did not completely resolve. Six months later, he returned with worsening symptoms, andvenography revealed in-stent restenosis. The patient requested simultaneous treatment on theleft side. The right stent was dilated, and a 3-cm-long occlusion of the left innominate vein wasrecanalized, again using sharp needle technique, homing into the struts of the right-sidedstent. Following fenestration of the stent, a second stent was deployed from the left sideinto the SVC, and the two Y limbs were sequentially dilated to allow a true bifurcation anatomy(figure). The patient had complete resolution of his symptoms and continues to do well 6months later.

INTRODUCTION

The superior vena cava (SVC) syndrome (SVCS)

results from both external compression and intralu-

minal thrombosis of the SVC. This most commonly

occurs as a result of right-sided pulmonary malig-

nancy, metastatic disease, or mediastinal tumors,

such as lymphomas, although rarer infectious and

rheumatologic etiologies have been well described.1

The rapidity with which this obstructive process

develops along with the presence of collateral circu-

lation determines not only the broad progression of

symptoms but also the urgency of treatment.2 The

primary pathophysiology of this disease relates to

the sequelae of venous hypertension in the veins

that drain into a partially or completely occluded

Fig. 1. Chest computed tomography (CT) image showing

multiple mediastinal lymph nodes and pulmonary paren-

chymalcalcificationsalongwithsuperiorvenacavaocclusion.

t of Surgery, University of Iowa, Iowa City, IA.

ence to: Parth Amin, MD, Department of Surgery,Iowa, 1500 JCP, Iowa City, IA, USA; E-mail:iowa.edu

g 2012; 26: 276.e5e276.e9j.avsg.2011.10.005ascular Surgery Inc.

276.e5

Fig. 2. Venogram and cavogram show complete superior

vena cava occlusion at its junction with right brachioce-

phalic vein. Contrast filling into azygos vein and right

intercostal veins as collaterals, which are also seen in

the right shoulder and neck areas. The left brachioce-

phalic vein is completely occluded in its mid-segment

with contrast filling into superior intercostal veins.

Fig. 3. Post recanalization and stenting.

Fig. 4. CT venogram showing in-stent restenosis. The CT

scan was ordered because of a worsening symptom

profile.

Fig. 5. Venogram showing in-stent restenosis.

276.e6 Case reports Annals of Vascular Surgery

SVC. The resulting symptoms include dyspnea,

facial or arm swelling, head fullness, and hoarseness

and cough.

If SVCS is extremely severe, cyanosis and coma

can occur. Any position that is dependant, such as

leaning forward, may produce these symptoms, or

clue a diagnostician into a more subtle or well-

compensated SVCS.3 By 1965, there were nearly

50 cases of successful surgical treatment of the

SVC syndrome, the majority of which were vein

bypass grafts. Although these cases reported

improvement of symptoms, the long-term results

were unknown.4 At present, treatment options

include primary lesion treatment with radiotherapy

or chemotherapy, surgical bypass, thrombolysis,

and more recently, endovascular stenting.1e4

CASE REPORT

We present the case of a 42-year-old, active, nonsmoking

man with no past medical history who describes a chief

complaint of facial swelling and a feeling of increased pres-

sure after picking up items from the floor and after signif-

icant cardiovascular activity. Initially, he tolerated these

Fig. 6. (A) Initial recanalization of the left innominate

vein. (B) Initial recanalization of the left innominate

vein.

Fig. 7. Recanalization using Y-stent technique.

Vol. 26, No. 2, February 2012 Case reports 276.e7

symptoms for approximately 6 years, but became con-

cerned when he developed a right anterior neck mass,

just above the lateral portion of his right clavicle. This

mass was biopsied and found to be benign; at the time, it

was considered to be a reactive lymph node.

A computed tomography scan was then performed,

with the finding of complete occlusion of the SVC

(Fig. 1). After a workup including mediastinoscopy and

laboratory testing, the diagnosis of mediastinal fibrosis

caused by histoplasmosis was made. The patient was

subsequently sent to interventional radiology for a veno-

gram and attempt at stenting. Recanalization was unsuc-

cessful, and the patient was referred to us (Fig. 2). By

now, his symptoms had progressed to where he had posi-

tional headaches and shortness of breath with activity. A

venous duplex was performed showing patent and

compressible bilateral internal jugular, brachial, and

femoral veins. At this point, we discussed options and

decided to reattempt recanalization.

He was taken to the catheterization laboratory, and

access was obtained into the left internal jugular, right

common femoral, and right basilic veins. Venography

confirmed chronic occlusion at the innominate venous

confluence (Figs. 3 and 4). Conventional recanalization

was attempted but was unsuccessful, so sharp recanaliza-

tion was used. A 10-mm snare was placed in the right

jugular subclavian confluence from the right basilic

approach and was used as a target for the 21-gauge Chiba

needle, which was introduced through a directional

Rosch-Uchida metallic cannula from the right common

femoral sheath. A guidewire was then snared through

and through. We predilated the occlusion by using

a 4-mm � 4-cm angioplasty balloon. We then deployed

a 14- � 40-mm Zilver stent (Cook, Bloomington, IN)

across the occlusion (Fig. 5). The Zilver stent did not

deform, likely because of its open-cell structure. We

decided not to attempt sharp recanalization of the left

occluded system because of its associated risk, having

achieved what we thought would be sufficient venous

decompression.

The patient was maintained on full anticoagulation

with oral warfarin therapy. Follow-up at 1, 3, and 6

months revealed resolution of most of his symptoms,

except for minimal positional and exertional ‘‘fullness.’’

However, at 1 year, he complained that his symptoms

were worsening again, and therefore, a computed tomog-

raphy venogram was performed showing an in-stent

restenosis (Fig. 6). We discussed endovascular treatment

of this restenotic segment but also planned recanalization

of the left proximal-most innominate vein with Y-stent

reconstruction, if feasible. We established access into the

Fig. 8. Idealized depiction of the Y-stent technique.

276.e8 Case reports Annals of Vascular Surgery

right common femoral vein and left basilic vein. Venog-

raphy of the SVC, innominate, and subclavian venous

systems confirmed the presence of a concentric in-stent

restenosis of the right innominate vein within the stented

segment, whereas the SVC segment of the stent appeared

widely patent (Fig. 6).

There was an approximately 2 cm long segment

between the position of the innominate venous stump

and the stent. We performed sharp recanalization into

a snare positioned in the left innominate vein stump and

a of the 21-gauge Chiba needle/Rosch-Uchida metallic

cannula combination, which was introduced from the

transfemoral approach. A 0.018-inch guidewire was

pulled, achieving through-and-through access. We then

predilated the recanalized tract to 4 mm using a small

vessel balloon. Next, we dilated the struts of the previ-

ously placed stents by using an 8- � 40-mm balloon

(Fig. 7).

We then introduced a 14-mm-diameter � 4-cm-long

Luminexx stent from a groin approach, deploying it across

the interstices of the existing Zilver stent ensuring to land

the distal end well into the open stump of the left innom-

inate vein. Location of the stent was excellent, and it was

then dilated to 12 mm with an angioplasty balloon. We

thenwent from the groin again andwent through the cells

of the just deployed Luminexx stent toward the right

innominate vein and dilated it using a 10-mm high-

pressure conquest balloon. We ran that balloon also on

the left side, andwe also used a combination of kissing bal-

loonsdwith a 10-mm balloon on the right innominate

vein and a 9-mm one on the left innominate vein.

However, we noticed rapid recoil of the stent at the area

of the innominate veins’ confluence, with more than

50% to 60% recurrent recoil once the balloon inflation

was terminated. We decided to further support the

recoiled segments with balloon-expanded stent.

We placed a 10-mm-diameter � 18-mm-long Omni-

link stent (Abbot Omnilink, Abbott Park, IL) into the left

innominate segment and a 10-mm-diameter � 28-mm-

long Omnilink stent across the right innominate segment.

The appearance was much improved on the last angio-

gram although there was perhaps 30% residual stenosis

on the right side, but all in all, the appearance was

markedly improved with excellent forward flow on both

sides, with no filling of collaterals (Fig. 8). He was dis-

charged on oral warfarin. At 6 months, he reports no

symptoms. His positional and exertional feelings of full-

ness have resolved.

DISCUSSION

Endovascular options have shown substantial

promise as a primary treatment modality for SVCS.

Work done by Barshes et al. shows that primary

patency for both unilateral and bilateral stent place-

ment at 1 year is approximately 74% at 1 year when

used for benign disease and slightly lower for more

malignant lesions.5 A large series from Lanciego

et al. examined 149 patients treated with self-

expandable metal stents for SVCS and found

that most patients obtain substantial symptom relief

or resolution within 72 hours and remain function-

ally symptom-free for an average of 6 months,

although better results are obtained with assisted

interventions.6

Furthermore, it is clear that the results of radio-

therapy may take many weeks for symptom relief

and that the subsequent symptom improvement is

less substantial than stent placement.7 When exam-

ining the subset of patients with SVCS with benign

disease, the data are even more convincing. Work

from the Mayo clinic shows a 96% primary-

assisted patency rate of SVC stents when performed

for malignant disease. Surprisingly, traditional open

surgical approaches showed primary-assisted

patency rates of 68% during the same time

interval.8

Dinkel et al. report that primary patency of bilat-

eral branchiocephalic stenting for SVCS is inferior to

that of unilateral stenting, although the data do not

show statistical significance.9 Nevertheless, there

are limited data on sharp recanalization of complete

venous occlusions. Certainly, case reports are

Vol. 26, No. 2, February 2012 Case reports 276.e9

promising, but caution should be exercised and both

open and endovascular salvage plans for perforated

vessels need to be in place. For this reason, we

would advocate unilateral recanalization, while

reserving bilateral recanalization for primary treat-

ment failures.

Nevertheless, in this case, the resolution of symp-

toms in this young man seems to justify attempted

bilateral recanalization with close follow-up.

Furthermore, a kissing-stent technique was used

in this study as opposed to our method of creating

a fenestration. Fenestrated grafts are on the horizon

and will substantially expand the endovascular

applications; however, we hope to use this tech-

nique as a bridge until fenestrated-graft technology

becomes more accessible.

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