Stenting Through a Portacath for Totally Occluded Superior Vena Cava in a Case of Non-Hodgkin’s Lymphoma
- Volume 15 - Issue 3 - March, 2003
- Posted on: 8/1/08
- 0 Comments
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Case Report. A 73-year-old woman was diagnosed with non-Hodgkin’s lymphoma in March 2000 for progressive abdominal distension. She was given 6 courses of chemotherapy (cyclophosphamide, adriamycin, vincristine and prednisolone) through the right subclavian vein by placing a portacath in the right infraclavicular region. The portacath was left in situ. The patient did not receive radiation therapy. Her abdominal computed tomography (CT) scans showed complete resolution of the mass with some residual scarring.
The patient presented to our hospital with symptoms of shortness of breath, chest pressure and facial puffiness. Two months prior to admission, she began to notice bilateral periorbital edema, facial edema and orthopnea. Two weeks prior to admission, her symptoms progressed to include bilateral arm swelling.
On presentation, the patient was in moderate respiratory distress and was unable to breath comfortably while lying flat on her back. Her physical examination was remarkable for facial plethora and marked symmetric edema of her head, neck and arms. A provisional diagnosis of SVCS was made. The patient was taken to the cardiac catheterization laboratory, where venous access was obtained via the right femoral vein and the right internal jugular vein. The mean pressure in the cephalad SVC was 32 mmHg. The right atrial pressure was 10 mmHg. Total occlusion of the SVC was demonstrated by simultaneous venography cephalad to the obstruction and right atrial angiography caudal to the obstruction (Figure 1). The occlusion measured about 5 cm in length.
The portacath was explanted from the subcutaneous pocket under local anesthesia and the venous sheath was cannulated with a single puncture needle. A 0.032´´ double-length Terumo guidewire (Terumo Corporation, Somerset, New Jersey) was passed through the lumen of the sheath inside the right atrium and to the inferior vena cava. To provide access across the obstruction from below, the Terumo wire was snared with a simple angioplasty guidewire, which was bent to hook the Terumo guidewire (Figure 2). A 6 French (Fr) right guiding catheter was used to support the angioplasty guidewire. After hooking the Terumo wire inside the guiding catheter, it was snared out via the right femoral venous access and withdrawn out of the right femoral vein. The Judkins right coronary catheter was then positioned via the right femoral vein across the SVC obstruction and simultaneously the portacath sheath was pulled into the right subclavian vein. The Terumo wire was exchanged with a 0.018 Platinum angioplasty guidewire and placed inside the right subclavian vein. A 4-cm long, 6-mm diameter balloon catheter (Symmetry) was then positioned across the SVC obstruction over the angioplasty guidewire. The obstruction was dilated at 10 atmospheres (atm) for 2 minutes with restoration of antegrade SVC flow. A narrow residual lumen with thrombus was evident soon after balloon deflation. The 6 mm balloon was exchanged with a 12-mm diameter, 6-cm long XXL balloon over the guidewire across the area of residual stenosis and dilated with 12 atm. The SVC lumen showed thrombus and residual stenosis after balloon dilatation. A 64-mm long, 14-mm compressed diameter, self-expanding Easy wall stent (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) was delivered to the SVC, covering the whole length of the obstruction with the proximal portion lying in the right atrium. A light “waist” remained in the middle portion of the stent (Figure 3).