Teaching Case

Tumor compression of large upper mediastinal veins

Patient presented with bilateral arm swelling, problems of breathing and enlarged jugular veins. CT revealed a large mediastinal tumor mass probably due to a bronchial carcinoma with occlusion of right innominate vein, thrombosis of right jugular vein, occlusion of left innominate vein and a collateral circulation. Angiography performed via the left basilic vein showed complete occlusion of left innominate vein and a lollateral flow through smaller mediastinal veins. The occlusion could be entered easily shoiwing tumor compression mixed with thrombus (Fig. 1a). A huge tumor mass compressed the confluens of the innominate veins (Fig. 1 b) which was difficult to pass by catheter and guidewire.

The tumor mass could be only passed by use of a hydrophilically coated 4 F catheter (Terumo Inc.) and a 0.035 in hydrophilic guidewire which were guided into the inferior vena cava. After having changed the guidewire for a 0.035 heavy duty Amplatz wire (Cook Inc.) whose tip was placed into the inferior vena cava to avoid damage to the right atrium, a predilation with a 6 mm balloon was performed followed by implantatation of two long 14 mm wide self-expanding stents (Wallstent, BSIC). The stents were then dilated to 10 mm by use of a standard balloon. All intervention was performed via the brachail access. Following that procedure, flow through the innominate vein was restored. In case of upper venous obstruction due to malignant tumours, stenting is a method that gives immediate relief to the patient. It can be considered as an emergency procedure. There is some discussion whether thrombolysis should precede balloon dilation and stenting in the presence of thrombus in order to avoid pulmonary embolization. In our experience, however, thrombolysis is not necessary because risk of embolization low if a careful predialtion by a small diameter balloon is followed by immediate stent placement and full dilation thereafter. Stents can reshape both a thrombotic occlusion and also displace tumor masses aside. Thrombolysis, however, bears some risk in tumour patients and is time-consuming. After stenting, there is no contraindication to chemotherapy or radiation because self-expanding stents will follow to open if tumor regression take place. Although bilateral obstruction was present, it is usually sufficient to open one side to offer a main collateral that allows drainage also of the contralateral side. Bilateral stenting may be considered in some cases e.g. if both jugular veins are occluded preventing collateral flow from one side to another. The patient had immediate relief of his complaints within 24 hours and underwent subsequent chemotherapy. Two months after treatment, the stent was still patent. Prognosis is however, limited by the underlying illness. Mechanical recanalization of malignant central venous obstruction is a successful approach in a potentially life-threatening situation. Clinical success is high with a rate of more than 90%. Patency is sufficient in most patients.