Teaching Case

Superior vena cava syndrome in a patient with bronchial carcinoma and a central venous port catheter placed across the obstruction

The patient suffered from known adenocarcinoma of her left lung and central mediastinal lymph node metastasis. Overtime she had developed clinical signs of superior vena cava syndrome despite chemotherapy, for which a port catheter system had been inserted into the left subclavian vein. Angiography revealed tight stenosis of the cranial portion of the superior vena cava causing collateral drainage via the azygos vein and mammarian vein (Fig. 1). The end of the port catheter was located within the right atrium. It was decided to recanalize the superior vena cava by stent implantation.

For safe stent placement and in order to keep the port catheter working it was planned to displace the port catheter temporarily to allow stent placement. For that purpose, the right cephalic vein was punctured and a 6 F snare catheter together with a 15 mm gooseneck snare was introduced into the right atrium (Fig.2). The snare was closed around the tip of the port catheter and pulled back into right subclavian vein where the catheter was parked during the intervention. Then a 10 F sheath was introduced via the cephalic vein and a 16 mm wide 45 mm long Wallstent was placed into the superior vena cava wihout overriding the innominate junction (Fig. 3). Since the tight stenosis compressed the stent after placement, a 15 mm wide and 4 cm long balloon (BSIC) was introduced and the balloon was inflated inside the stent allowing opening of the implant, Then, a right femoral venous puncture was performed and the snare catheter was advanced through the stent into the right subclavian vein (Fig. 4). The tip of the catheter was caught and the partially open snare was managed to the apex of the catheter at the level of the innominate junction. Then the catheter was pulled through the stent into the right atrium where it was left (Fig. 4). Treatment of vena cava syndrome by stents is an accepted concept. In case of implanted central venous catheters, placement can be complicated . Temporary displacement of the catheter is an elegant method to keep the catheter in function but also to allow safe placement of the stent.