VENOUS

SUPERIOR VENA CAVA STENT

Introduction

Last updated: may 14, 2025

The majority of superior vena cava obstruction cases (over 85%) are caused by underlying malignancies, with lung cancer and lymphoma being the most common. The median life expectancy secondary to malignancy is only 6 months. However, a growing proportion of cases are due to benign conditions, often resulting from long-term use of central venous catheters or prior cardiac procedures.

 

Presentation

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Anantomical Classification of VCS
 

Anatomy

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Anantomical Classification of VCS
 

Indications

Symptomatic obstruction of the superior vena cava

  • Facial/neck edema 60-100%
  • Distended neck and chest veins27-86%
  • Dispnea and cough 23-70%
  • Upper extremities edema 14-75%
  • Hoarsness and stridor 0-20%
  • Syncope and headache 6-13%
  • Confusion 0-5%
  • Rarely esophageal varicose

 

Contra indications

Absolute

  • No absolute contraindications

Relative

  • A very good chance of early cure or remission
  • Inability to lie flat or semi-supine
  • Systemic sepsis
  • Noncorrectable coagulopathy.

 

Workup

  • CTV

 

Pre procedural

Review prior imaging (MDCT or MRI) to assess:

  • Extent and length of venous obstruction
  • Relationship with mediastinal structures
  • Normal venous diameters
  • Presence of thrombus
  • Involvement of brachiocephalic veins
  • Collateral formation
  • Determine vascular access site based on imaging and anatomy

 

Materials

Essentials

Catheters

  • 4–5 Fr diagnostic catheters
  • Multipurpose
  • Cobra
  • Sidewinder
Guidewires
  • 0.035” standard guidewires (varying stiffness)
  • 0.035” hydrophilic guidewires (varying stiffness)
  • 0.018" v18
Vascular Access Sheaths
  • 5–12 Fr sheaths: standard length and long
Balloon Catheters
  • Standard balloon dilatation catheters
  • Diameter range: 6–20 mm
  • High-pressure balloon catheters (if needed)
  • Diameter range: 12–18 mm
Stents
  • Large diameter self-expanding bare metal stents
  • Diameter range: 12–24 mm
  • Covered stents (in case of venous rupture)
Emergency Pericardiocentesis Kit
  • Access needles
  • Guidewires
  • Catheters or drains

Non-Essentials

 

Positioning the patient

  • Head first
  • Supine
  • Head elevated if needed

 

The procedure in steps

  • Time out
  • Sterile washing
  • Draping
  • Ultrasound-guided venipuncture
  • Standard physiological monitoring:
    • Pulse
    • Blood pressure
    • Oxygen saturation
    • ECG
  • Vascular Access
    • Preferred: Femoral
    • Also upper limb vein bilaterally for imaging
  • Superior vena cavogram
  • Cross the obstruction under fluoroscopic guidance
  • Balloon Pre-Dilatation if necessary
  • Stent deployment
  • Post-Stent Balloon Dilatation (if needed)
  • Completion Venogram
  • Sign out

Acute Overload Syndrome Cause: Rapid recanalisation of SVC leading to increased venous return and right heart pressures Symptoms: Pulmonary oedema Management: Diuretics Positive pressure ventilatory support ICU monitoring Prevention: Consider pre-procedural echocardiography in patients with impaired cardiac reserve or valvular disease

Stent Migration Complications Risk: Into the right atrium Consequences: Cardiac arrhythmias, significant morbidity, occasional mortality Predisposing factors: Poor pa tient selection Inadequate stent oversizing Inadequate stent positioning or deployment Cardiac motion Inaccurate vessel measurement

 

Tips and tricks

Stent length/diameter:

  • Should cover the lesion with ~10 mm overlap at both ends
  • Recommended: 60% of stent length above the lesion
  • Extend to brachiocephalic vein if necessary
  • Overlapping stents may be needed for longer lesions
  • Self-expanding bare metal stents (most common)
  • Usually oversized by up to 2 mm compared to reference vessel
  • Avoid >16 mm if concerned about increased risk of complications (controversial)

 

Complications

  • Pericardial tamponade
  • SVC rupture
  • Stent migration
  • In-stent restenosis
  • Pulmonary edema
  • Major bleeding
  • Pulmonary embolism
  • Cardiac injury
  • Cardiac failure
  • Arrhythmias
  • Chest pain
  • Infection
  • Restenosis
  • Death

Acute Overload Syndrome
Cause:
  • Rapid recanalisation of SVC leading to increased venous return and right heart pressures
Symptoms:
  • Pulmonary oedema
Management:
  • Diuretics
  • Positive pressure ventilatory support
  • ICU monitoring
Prevention:
  • Consider pre-procedural echocardiography in patients with impaired cardiac reserve or valvular disease

Stent Migration Complications
Risk:
  • Into the right atrium
Consequences:
  • Cardiac arrhythmias, significant morbidity, occasional mortality
Predisposing factors:
  • Poor patient selection
  • Inadequate stent oversizing
  • Inadequate stent positioning or deployment
  • Cardiac motion
  • Inaccurate vessel measurement
 

Post-op

  • 75 mg Clopidogrel daily
  • 80 mg Acetylsylicic acid daily for 3 months

 

Follow-up

  • Clinical follow-up usually every 3 months
  • Repeat venography if symptoms recur

 

Report

 

Patient folder

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Literature

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The information contained herein has been obtained from sources believed to be reliable. However, no warranty as to the accuracy, completeness or adequacy of such information is implied. No liability is accepted for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice.

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