Síndrome de vena cava superior: una serie de casos consecutivos en pacientes internados en un hospital terciario universitario / Superior vena cava syndrome: a consecutive case series of in-hospital patients in a tertiary teaching hospital

Introducción: el síndrome de vena cava superior resulta de la obstrucción del flujo sanguíneo a través de este vaso. Casi la totalidad de los casos en la actualidad se asocian con tumores malignos. Existen controversias acerca del manejo apropiado de este cuadro. Actualmente, las terapias endovasculares son consideradas de elección. Materiales y métodos: se recolectaron y describieron, a partir de datos de la historia clínica electrónica, los casos de pacientes mayores de 18 años internados ­de forma consecutiva, que desarrollaron el síndrome­ en el Hospital Italiano de Buenos Aires en 2021. Se constataron las características basales, los tratamientos recibidos y los desenlaces clínicos intrahospitaliarios de cada uno de ellos. Resultados: un total de cinco pacientes fueron incluidos en el presente estudio y seguidos durante su instancia intrahospitalaria. Todos los casos descriptos fueron secundarios a enfermedades oncológicas. La mayoría de los pacientes presentaron un cuadro de moderada gravedad según las escalas utilizadas. En cuatro de cinco pacientes se optó por terapias endovasculares y dos de ellos fallecieron durante la internación. Discusión: existen controversias respecto del tratamiento óptimo del síndrome de vena cava superior, y heterogeneidad en la práctica clínica. Los estudios futuros deberían centrarse en identificar a aquellos pacientes que más probablemente se beneficien de las estrategias terapéuticas endovasculares, anticoagulantes o antiagregantes. (AU)

Introduction: superior vena cava syndrome results from an obstruction of blood flow through this vessel. Currently, almost all cases are associated with malignancies. There are controversies about the optimal management of this syndrome. Endovascular therapies are considered the first-line therapy. Material and methods: we collected clinical, laboratory and pharmacological data from patients admitted at the Hospital Italiano de Buenos Aires, between January 1st and November 1st 2021 with a diagnosis o superior vein cava syndrome. Baseline characteristics, treatment strategies and clinical outcomes were recorded. Results: a total of five patients were included in the present study. All cases were malignancy-related. Most of the patientsdeveloped moderate symptoms. Four out of five patients were treated with endovascular therapies and two patients died during hospitalization. Discussion: controversies regarding optimal management of the superior vena cava syndrome remain. Future research should focus on identifying those patients who are most likely to benefit from endovascular, anticoagulant or antiplatelet therapeutic strategies. (AU)

Efficacy of endovascular Z-configuration stenting for malignant versus nonmalignant caval obstruction.

OBJECTIVE: The objective of this study was to assess factors associated with symptom resolution after endovascular stenting for superior or inferior vena cava syndrome. METHODS: Eighty-six consecutive vena cava Z-configuration stent placements in 82 patients (53 ± 14 years old) at a single institution were reviewed for patient demographics, comorbidities, and durability of stent patency (also evaluated were persistent or recurrent symptoms, stent occlusion, and need for repeated stenting). Logistic regression was used to identify independent factors associated with stent patency, and Φ coefficients and analysis of variance were used to compare cases subdivided by lesion location (superior vena cava, inferior vena cava) and the presence or absence of malignant disease. RESULTS: Clinical follow-up was available in 77 of 86 (90%) cases. Technical success with clinical failure (persistent symptoms) occurred in 40% of these cases with a median follow-up of 67 (interquartile range, 14-570) days and mortality rate of 63% during this period. Malignant obstructions had a significantly higher clinical failure rate of 54% compared with 15% for nonmalignant obstructions (Φ = 0.34; P = .002). However, only metastatic disease was independently associated with clinical failure when controlling for demographics, other comorbidities, and differential follow-up (adjusted odds ratio, 8.27; 95% confidence interval, 2.79-24.50). CONCLUSIONS: Vena cava Z-stenting effectively resolves symptoms in 85% of nonmalignant obstructions compared with only 46% of malignant obstructions. Patients should be counseled accordingly, and those with malignant obstructions may require closer follow-up to evaluate the need for reintervention and goals of care.

Computed Tomography Findings Associated With 30-Day Mortality in Patients With Malignant Superior Vena Cava Syndrome.

OBJECTIVE: The objective of this study was to identify radiological and clinical factors associated with early mortality in malignant superior vena cava syndrome (SVCS). MATERIALS AND METHODS: Chest computed tomography studies of 127 patients with malignancy-associated SVCS were retrospectively reviewed. Involvement of SVC and tributaries, pleural and pericardial effusions, pulmonary artery involvement, and ancillary findings were documented. Univariate and multivariate models determined associations between radiological and clinical variables, and 30-day mortality. RESULTS: Thirty-day mortality rate was 16.5% (n = 21). Factors associated with 30-day mortality on univariate analysis included age, cancer stage, SVCS clinical severity, left jugular vein obstruction, number of involved veins, pulmonary arteries involvement, and presence of pleural effusions. Age, SVCS clinical severity, number of veins involved, and pleural effusions were positively associated with 30-day mortality on multivariate analysis. CONCLUSIONS: Selected clinical and radiological variables are associated with early death in malignant SVCS. These factors may identify a subgroup of patients who may benefit from treatment escalation.

Evaluation of stent placement for vena cava syndrome: phase II trial and phase III randomized controlled trial.

PURPOSE: Vena cava syndrome (VCS) from stenosis of the superior vena cava or inferior vena cava caused by compression from a malignant tumor is one of the typical clinical conditions in patients with advanced stage malignant disease. VCS is difficult to manage and painful, reducing patients' quality of life. Although several reports have investigated stent placement for VCS, this treatment has never been established as the standard because of the lack of evidence of the safety and efficacy. We conducted a phase II trial and a phase III randomized controlled trial to clarify the role of stent placement in managing patients with VCS. METHODS: In the phase II trial, 28 eligible patients were treated with stent placement. The efficacy of stent placement for VCS was evaluated based on the reduction of patients' symptom scores during 14 days following treatment. Technical success, technical feasibility, overall survival, recurrence of symptoms, and adverse events were evaluated. In the phase III trial, 32 patients were enrolled and randomly assigned to the test (n = 16) and control groups (n = 16). The area under the symptom score curve was compared between the groups. The EQ-5D, SF-8, and adverse events were evaluated until discontinuation of the protocol treatment or 28 days after enrollment. RESULTS: In the phase II trial, the median patients' symptom scores significantly decreased from 10.50 before the procedure to 3.00 after the procedure. Technical success and technical feasibility rates were 96.4% and 100%, respectively. The incidence of treatment-related grade 3 or higher adverse events was 14.3%. In the phase III trial, significant superiority of stent placement was observed in the test, compared to that in the control, group. There was no significant difference in most other evaluations between the groups. CONCLUSIONS: Stent placement significantly improved the symptoms of VCS; thus, it might be accepted as the standard treatment to manage the symptoms of VCS. TRIAL REGISTRATION: JIVROSG-0402, JIVROSG-0807.

Thrombosis, anticoagulation and outcomes in malignant superior vena cava syndrome.

Anticoagulation is often used in superior vena cava syndrome (SVCS) associated with cancer (i.e malignant SVCS), even without thrombosis, but its effect on outcomes has not been reported. We aimed to determine factors and outcomes associated with thrombosis and anticoagulation in malignant SVCS. Patients with malignant SVCS diagnosed on computerized tomography (CT) were retrospectively included, indexed at diagnosis and followed for 6 months using medical records. The cohort included 183 patients with malignant SVCS of which 153 (84%) were symptomatic. Thirty of the 127 patients (24%) with a reviewable baseline CT had thrombosis of the SVC or tributaries at diagnosis. Patients with baseline thrombosis more often had symptomatic SVCS (p < 0.01). 70% (21/30) of patients with thrombosis and 52% (49/97) of those without thrombosis at baseline received anticoagulation, most often at therapeutic doses. Thrombosis occurred in 5/39 patients with anticoagulation (13%) compared to 2/18 (11%) of those without, during follow-up (p = 0.85). Anticoagulation was associated with a reduction in risk of SVC stent placement during follow-up that did not reach statistical significance (HR 0.47, 95% CI 0.2-1.13, p = 0.09). Major bleeding occurred in 7 (4%) patients, six of whom received anticoagulation (four therapeutic and two intermediate dose). Neither thrombosis nor anticoagulation affected survival. Anticoagulation is commonly used as primary prevention but its benefit remains to be proven. The role of reduced-dose anticoagulation in non-thrombotic malignant SVCS should be prospectively assessed.

Longevity after radiotherapy of stage III lung cancer: superior vena cava obstruction is associated with early mortality.

BACKGROUND: People with locally advanced lung cancer have a poor prognosis. Physicians are unable to accurately predict life expectancy of patients. The aims of this retrospective study were to identify the life spans of individuals after radiotherapy of stage III carcinoma of the lung and to determine whether potential prognostic factors could identify people with distinct life spans. METHODS: Between September 1981 and August 2010, 133 consecutive individuals underwent definitive or palliative radiotherapy (with or without chemotherapy) for stage IIIA/IIIB disease. Analysis of the survival data revealed that 14 patients experienced long-term survival, exceeding 36 months; 94 patients had a short-term life span (STLS), extending between 4 and 36 months, and 25 patients were in the end-of-life (EOL) period, referring to the last 3 months of life. Recognized pre-treatment clinicopathological features were tested for their impact on prognosis. RESULTS: The largest proportion of patients presenting with superior vena cava obstruction (SVCO) (P<0.001) and receiving palliative radiotherapy (P=0.009) were from the EOL group. Most of the individuals with inadequate or no health insurance belonged to the STLS and EOL cohorts (P=0.001). Multivariate analysis revealed that the presence of SVCO was an independent factor predictive of shortened survival/EOL status (P=0.001). CONCLUSIONS: Our study showed that a particular disease characteristic, health insurance status and provision of contemporary therapy can influence individual longevity. Selection and prioritization of health care resources remain important; therefore, identification of influential prognostic factors in lung cancer patients deserves further scrutiny.

Stent insertion for malignant superior vena cava syndrome: effectiveness and long-term outcome.

PURPOSE: To determine the clinical effectiveness and long-term outcome of stent insertion for malignant superior vena cava (SVC) syndrome. MATERIALS AND METHODS: From June 2010 to April 2016, 47 patients with malignant SVC syndrome were treated with stent insertion in our center. Data regarding the technical success, clinical success, and long-term outcome were collected and analyzed retrospectively. RESULTS: SVC stent insertion was successfully performed in all patients. A total of 65 stents were used. No procedure-related complication occurred in these patients. The mean SVC pressure gradient decreased from 17.8 mmHg before stent insertion to 7.6 mmHg after stent insertion (P < 0.001). Clinical success was 100%. During a mean follow-up period of 6 months (range 10 days-13 months), 25 patients underwent subsequent anti-cancer treatment. Six patients (12.8%) experienced re-obstruction of stent 1 to 189 days (median 76 days) after stent insertion. All patients died during the follow-up. The median stent patency time and survival were 339 and 167 days, respectively. The cumulative 3-, 6-, and 12-month stent patency rates were 93.4, 87.4, and 81.2%, respectively. The cumulative 3-, 6-, and 12-month survival rates were 83, 38.3, and 2.1%, respectively. The independent predictors of prolonging survival after stent insertion were lower tumor stage (P = 0.018) and subsequent anti-cancer treatment after stent insertion (P = 0.009). CONCLUSION: Stent insertion is a simple, safe, and effective method for patients with malignant SVC syndrome. Subsequent anti-cancer treatment after stent insertion may increase the survival.

Stent Implantation for Superior Vena Cava Syndrome of Malignant Cause.

Purpose The purpose of this paper is the retrospective analysis of endovascular therapy for the treatment of superior vena cava syndrome (SVCS) of malignant cause. This study focuses on the effectiveness of the therapy regarding the duration of remission, symptom control and practicability. Materials and Methods From January 2003 to November 2012, therapeutic implantation of one or more stents was performed in 141 patients suffering from SVCS. The medical history was retrospectively researched using digitalized patient files. If those were incomplete, secondary research was conducted using the cancer registry of the General Hospital Nuremberg, the cancer registry of the tumor center at Friedrich-Alexander-University Erlangen-Nuremberg (FAU) or information given by physicians in private practice. This data was collected using Microsoft Office Excel® and statistically analyzed using IBM SPSS Statistics 22®. Results 168 stents were implanted in 141 patients (median age: 64.6 years; range: 36 - 84), 86 being male and 55 being female. In 121 patients, SVCS was caused by lung cancer (85.8 %), in 9 patients by mediastinal metastasis of an extrathoracic carcinoma (6.4 %), in 3 patients by mesothelioma of the pleura (2.1 %) and in 1 patient by Hodgkin's disease (0.7 %). There was no histological diagnosis in 7 cases (4.9 %). The primary intervention was successful in 138 patients (97.9 %). Immediate thrombosis in the stent occurred in the remaining 3 cases. Recurrence of SVCS was observed in 22 patients (15.6 %), including 5 early and 17 late occlusions. Stent dislocation or breakage was not observed. As expected, the survival after implantation was poor. The median survival was 101 days, and the median occlusion-free survival was 80 days. Conclusion The symptomatic therapy of SVCS with endovascular stents is effective and safe. Despite effective symptom control and a low rate of recurrence, the patients' prognosis is poor. Key Points: · Patients with SVCS of malignant cause have a poor prognosis.. · Lung cancer is the most common cause for SVCS.. · Endovascular therapy is safe and effective.. Citation Format · Büstgens FA, Loose R, Ficker JH et al. Stent Implantation for Superior Vena Cava Syndrome of Malignant Cause. Fortschr Röntgenstr 2017; 189: 423 - 430.

Covered stent placement for the treatment of malignant superior vena cava syndrome: is unilateral covered stenting safe and effective?

OBJECTIVE: To evaluate the safety and efficacy of unilateral covered stent placement in patients with malignant superior vena cava (SVC) syndrome. MATERIALS AND METHODS: Between October 2008 and November 2012, expanded polytetrafluoroethylene-covered stent placement for malignant SVC syndrome was performed in 40 consecutive patients (35 men and five women; mean age, 61.4 years; range, 35-81 years). All covered stents were unilaterally placed within the SVC or across the venous confluence when needed to relieve venous obstruction and prevent tumor overgrowth, regardless of patency of contralateral brachiocephalic veins. RESULTS: Stent placement was technically successful in all patients. There were no major complications. Of the 37 patients symptomatic prior to stent placement, 34 (92%) experienced complete symptomatic relief 1-8 days after stent placement. Of the 29 patients who underwent covered stent placement across the venous confluence, nine patients had patent contralateral brachiocephalic veins prior to stent placement. However, no sign of SVC obstruction or contralateral upper extremity venous thrombosis was observed during the follow-up period. Kaplan-Meier analysis revealed median patient survival of 163 days. Stent occlusion occurred in four (10%) of 40 patents. Cumulative stent patency rates at 1, 3, 6, and 12 months were 95%, 92%, 86%, and 86%, respectively. CONCLUSION: Unilateral covered stent placement appears to be a safe and effective method for treating malignant SVC syndrome, despite the location of SVC occlusion.

Patient-provider delays in superior vena caval obstruction of lung cancer and outcomes.

This retrospective study investigates the types of delay in the initiation of palliative thoracic radiotherapy for superior vena caval obstruction (SVCO) of lung cancer (LCa) and the effect of treatment delay on patient outcomes. Treatment delays were categorized as patient delay (duration of symptoms), in-hospital delay, and professional delay and were determined in 42 people treated by radiation for palliation of the complicated neoplastic condition between 1981 and 2009. The median period of patient delay was 26.2 days, in-hospital delay was 3.5 days, and professional delay was 1.5 days. The majority (80%) of these individuals were uninsured or underinsured, and 69% presented with locally advanced LCa. The overall response rate was 84%, and the 1-year survival rate was 24%. Despite the longest patient-related delay, symptomatic individuals overall derived palliation from conventional treatment. Improved efforts toward early diagnosis and treatment of patients with SVCO-LCa need to be continued.

[Syndrome of vena cava superior in the injured persons with traumatic instability of a sternocostal skeleton as a consequence of polytrauma].

There were analyzed 8 clinical observations of treatment of syndrome of vena cava superior in the injured persons in traumatic instability of a sternocostal skeleton. Peculiarities of course of traumatic process, concerning the trauma severity objective prove, were established.

Profile and factors associated with mortality in mediastinal mass during hospitalization at Cipto Mangunkusumo Hospital, Jakarta.

AIM: to obtain characteristics, variations of the type of mass, diagnostic modalities, and mortality factors during hospitalization in patients with mediastinal mass at our institute during a 10-year period. METHODS: a case-control study was conducted, by browsing through the medical records of 113 mediastinal mass patients who were treated at Cipto Mangunkusumo Hospital, Jakarta, during a 10-year period (January 2000-December 2009). Factors associated with mortality, i.e; sepsis, septic shock, pneumonia, lung tuberculosis, superior vena cava syndrome, massive pleural effusion, pericard effusion, and respiratory failure were analyzed by logistic regresion multivariate analysis. RESULTS: two hundred and one mediastinal mass patients were diagnosed and treated at our institute, 113 medical records were available to be included in this study. There were 69 males and 44 females with the age range of 18-60 years. One-hundred and seven patients were symptomatic at presentation. Mediastinal tumor was the most common mediastinal mass found among the subjects. The most frequent mass location was in the anteriosuperior compartement. Chest X-ray imaging were able to detect 61 cases of mediastinal mass, while 42 patients underwent thoracotomy (open biopsy) to acquire histopathology diagnosis. The proportion of mortality during hospitalization reached 39.8%. Logistic regression multivariate analysis found sepsis (p=0.000), superior vena cava syndrome (p = 0.000), and massive pleural effusion (p=0.047), were significant factors associated with mortality during hospitalization. CONCLUSION: the clinical and radiologic features of mediastinal mass patients in our institute showed that mediastinal mass may resemble the symptoms of other diseases. Types and diagnostic modalities performed in our study differs from other studies previously reported in other countries with a high proportion of mortality during hospitalization.

Mid- and long-term follow-up experience in patients with malignant superior vena cava obstruction.

OBJECTIVES: Superior vena cava obstruction (SVCO) due to mitotic diseases is a serious condition with significant morbidity and mortality. The aim of this study was to examine the follow-up data and demographics of patients with SVCO admitted to the Department of Surgery, Queen Mary Hospital, over a 14-year period. METHODS: The prospectively entered clinical data of patients with SVCO in Queen Mary Hospital from October 1997 to September 2011 were retrospectively analysed. All patient records were electronically and manually searched. Survival was calculated using Kaplan-Meier survival curves analysis. The Mantel-Cox log-rank test was used to test for statistically significant differences. Demographic data, associated aetiology, intervention and outcome were studied. Only patients with malignant aetiologies were included. RESULTS: A total of 104 patients (81 males and 23 females) were recruited in our study period. Median age at presentation was 65 (range 3-91 years). The median follow-up period was 2 months. The commonest cause of SVCO was bronchogenic carcinoma (71%), followed by extrathoracic malignancies (16%), lymphoma (8%) and thymic malignancy (3%). The mean time from the onset of symptoms to presentation was 34 days. Steroids were prescribed for most (93.9%) of the patients. About half (54.4%) of the patients were given radiotherapy. Only 7 patients had angioplasty and all of them had stents inserted. The overall survival was poor. The mean and median survivals were 8.4 and 1.6 months, respectively. Seventeen percent of patients died in the same hospitalization as for their initial presentations. Younger age (50 years or below; P = 0.000), never smoker (P = 0.012), not using steroids (P = 0.007) and certain primary aetiologies (e.g. lymphoma; P = 0.008) were associated with longer overall survival on univariate analysis. However, on multivariate analysis, none of these factors reached statistical significance. The mean survival for cases with lymphoma, extrathoracic malignancies, bronchogenic tumours and thymic tumours was 80.1, 3.4, 3.1 and 1.8 months, respectively. Angioplasty did not show a statistically significant association with the overall survival. CONCLUSIONS: This study, to the best of our knowledge, is the first to study the prognostic factors that may affect survival outcome in malignant SVCO. We showed that in patients with malignant aetiology for SVCO, advanced age (more than 50), history of smoking and use of steroids were statistically significantly associated with a poor outcome. The underlying primary malignant aetiology also has an important prognostic significance. Despite advances in medicine, the prognosis of patients with SVCO is still grave.

[Results of surgical treatment of patients with solid malignant chest tumours and superior vena cava syndrome].

Superior vena cava syndrome results from blood flow disturbances caused by compression or tumour invasion of the superior vena cava and its tributaries. In most cases, malignant lung tumours are responsible for its development. In 1995-2010, we performed surgical treatment of 55 patients with malignant chest neoplasms and superior vena cave syndrome. Vertical sternotomy was employed most frequently. Some patients additionally underwent antero-lateral thoracotomy to facilitate the surgical approach. Polytetrafluoroethylene prostheses 18-20 mm in diameter (Russia) were used to superior vena cava. Radical and cytoreductive surgery was the method of choice in 60 and 40% of the patients respectively. The signs of obstruction disappeared in all patients immediately after surgery. 21.8% of the patients died during the early postoperative period, 5 ones survived without signs of relapses. Median survival was 21 months.

Superior vena cava syndrome as tumour presentation.

UNLABELLED: Superior vena cava syndrome (SVCS) is characterised by gradual and insidious compression/obstruction of the superior vena cava (SVC). Upper chest and neck ingurgitation, plethoric face and oedema are the common symptoms/signs. It generally means the presence of neoplasm, namely lung cancer. AIM: Retrospective analysis of the patients admitted to S. João Hospital, Porto, Portugal, January 1995-December 2006 with SVCS without previous diagnosis. Patients, tumour characteristics and prognostic factors were studied. MATERIAL AND METHODS: Data was collected by consulting the clinical files of 60 SVCS patients without previous diagnosis. Data was gathered on the patients' demographic characteristics (age, gender, smoking habits), performance status, histology, staging, treatment and overall survival. RESULTS: Lung cancer was observed in 87% of the patients. Small-cell lung cancer (SCLC) was the most frequent histological type; 41% of the patients. It is noticeable that 10% were diagnosed with non- Hodgkin's lymphoma. In terms of prognostic factors analysed, the absence of metastasis, the lymphoma's histological diagnosis, good performance status and non-smoker status were positively correlated with the survival rate. On the contrary SCLC was significantly correlated with a worse survival. CONCLUSIONS: In our analysis we concluded that SCLC, smokers and a poorer performance status as well as metastatic disease were unfavourable prognostic factors to SVCS as tumour presentation.

[Stenting for superior vena cava obstruction associated with lung cancer: monocentric study]. / Mise en place précoce d'une endoprothèse dans les syndromes de la veine cave supérieure: étude monocentrique.

INTRODUCTION: Superior vena cava obstruction is an urgent complication of lung cancer. Superior vena cava stent insertion can be considered to provide rapid relief of the symptoms. METHODS: To estimate the efficiency and the complications of this procedure, we retrospectively analyzed 41 consecutive patients treated during the last 5 years by self-expanding nitinol stent insertion for superior vena cava obstruction due to lung cancer. It was combined with anticoagulation and corticosteroids. RESULTS: 41 patients benefited from this treatment (30 men and 11 women) with an average age of 59 years. Etiologies of the vena cava obstruction were: small cell carcinoma (11), adenocarcinoma (8), squamous cell carcinoma (9), large cell carcinoma (9) and others (4). All patients were symptomatic. The average period between the onset of symptoms and the vascular stenting was 14 days. Specific treatment was chemotherapy (18 patients), radiotherapy (1 patient), or both (14 patients), and no specific treatment for 6 patients. The procedure consisted of the insertion of 1 (73%) or 2 (27%) stents, with an average length and caliber of 7.5 cm and 14 mm respectively. No major complication was reported in short and long-term follow up. Symptomatic improvement was observed for all the patients within 48 hours. Median survival after the stenting was of 6.7 months. CONCLUSION: In our study, vascular stenting for malignant superior cava vena obstruction allows a rapid improvement of the symptoms with very few complications, suggesting a possible role as first line treatment for chemo or radio-resistant tumours.

Sequential treatment of superior vena cava syndrome caused by of non-small cell carcinoma lung cancer (NSCLC) with vascular stenting and iodine-125 implantation.

Feasibility and efficacy of sequentially performed endovascular stenting and Iodine-125 brachytherapy for malignant superior vena cava syndrome (SVCS) were evaluated. Thirty-four patients with malignant SVCS caused by NSCLC underwent sequential treatment of endovascular stenting and Iodine-125 brachytherapy. SVCS was diagnosed in all patients by CT images or vena-cavography. Pathology diagnosis was acquired by image guided biopsy. Endovascular stent placement was performed as first-line treatment for symptom relief. CT-guided Iodine-125 seed implantation performed 24hr after stenting. Clinical end points were resolution of symptoms and local efficacy of primary malignancy regression. Symptom relief rate was >90% after 24hr and 97% after 3 months. No migration of seeds or restenosis occurred in any patient. The local efficacy (defined as either partial or complete response) was 53%, 79%, 88% and 74% after 1, 3, 6 and 12 months, respectively. Mean SVCS-free survival time was 305 days (range 120-960 days). Two patients were still alive at the time of this writing, Thirty-one died from progression and one died from acute heart disease. Sequentially performed endovascular stenting and Iodine-125 brachytherapy provides a safe and effective alternative for malignant SVCS caused by NSCLC.

Surgical reconstruction of the superior vena cava system: indications and results.

BACKGROUND: Obstruction of the superior vena cava (SVC) secondary to malignant or benign diseases is rarely treated by surgical reconstruction. The purpose of this retrospective study is to report our experience and compare our results with previous data in the literature. METHODS: From 1993 to 2006, 24 patients underwent operative reconstruction of the SVC. Mean patient age was 58 years. The underlying disease was primary bronchopulmonary malignant neoplasm in 50%, mediastinal malignant neoplasm in 21%, and symptomatic benign disease in 29%. Forty-six percent of patients presented clinical signs of superior vena cava compression (SVCC). Our indications were based on two criterions: clinical symptoms of superior vena caval compression or histological examination of the superior vena caval lesion that indicates potential for complete surgical excision. RESULTS: Median duration of postoperative intensive care was two days. Mortality at 30 days was 12% for malignant diseases. All patients presenting clinical signs of SVCC improved. Mean follow-up was 28 months (range, 1-129). No thrombosis was observed during follow-up. Overall survival was 53% at 1 year and 35% at 5 years. For patients with malignant bronchopulmonary disease, survival was 50% at 1 year and 25% at 5 years. Mortality was 0% for patients with benign disease. CONCLUSION: Review of the literature indicates that replacement of the SVC is an uncommon procedure. Our experience suggests that the need for SVC reconstruction should not, however, be considered as a contraindication for resection of a bronchopulmonary or mediastinal neoplasm in an otherwise potentially curable patient, provided it can be achieved in a single block with clear margins. Replacement of the SVC can also be performed with low mortality and morbidity for effective treatment of SVCC secondary to benign disease that fails to respond to medical therapy.

[Surgical treatment of superior vena cava syndrome].

OBJECTIVE: To analyze the clinical features, especially surgical treatment of superior vena cava syndrome (SVCS). METHODS: The clinical data of 26 patients with SVCS, 19 males and 7 females, aged 37 (19-63), diagnosed base on the space occupying lesion in mediastinum and complete or incomplete obstruction of SVC and/or innominate vein by imaging examination without evidence of tumor in other parts and without evidence of lymphoma in the mediastinal lesion by pathological examination, who underwent surgical treatment were analyzed, focusing on the clinical presentation, preoperative examination, surgical treatment, pathological diagnosis, and survival. RESULTS: Facial cyanosis and edema, cervical and chest wall varicose veins, headache and dizziness, cough and dyspnea were the most common clinical manifestations. Pre-operative percutaneous needle biopsy guided by CT confirmed the diagnoses of malignant tumor of mediastinum in 6 cases and definite diagnoses failed to be got in the other 20 cases. Resection of the primary lesions combined with artificial blood vessel replacement of SVC was performed. Twenty patients received complete resection, and 6 received only incomplete excision because of extensiveness of lesions. The mean survival time of the former group was 30 months, significantly longer than that of the latter group (11 months, P = 0.0036). The overall 1-year survival rate was 69.2%, and 5-year survival rate was 7.6%. CONCLUSION: Resection procedure is an important factor influencing the prognosis of SVCS.

Benign superior vena cava syndrome: stenting is now the first line of treatment.

BACKGROUND: Endovascular repair (EVR) is emerging as first-line treatment for patients with superior vena cava (SVC) syndrome of benign etiology, but data on its durability remain scarce. The aims of this study were to assess the efficacy and durability of EVR and compare results of EVR with open surgical reconstruction (OSR). METHODS: Data from 70 consecutive patients undergoing treatment for benign SVC syndrome between November 1983 and November 2006 were retrospectively reviewed. RESULTS: There were 30 males and 40 females (mean age, 41 years; range, 5-75 years). Etiology included indwelling catheters or pacemaker wires in 35 patients, mediastinal fibrosis in 31, idiopathic thrombosis in 2, hypercoagulable disorder in 1, and postsurgical thrombosis in 1. In 42 patients, OSR was done through a median sternotomy: repair was with spiral saphenous vein in 22, expanded polytetrafluoroethylene (ePTFE) in 13, femoral vein grafts in 6, and human allograft in 1. Fifteen OSRs followed failed EVR interventions. EVR was attempted in 32 patients and was successful in 28 (88%): 19 had stenting, 14 had percutaneous transluminal balloon angioplasty (PTA), 2 had thrombolytic therapy with PTA, and 3 had stenting. All four technical failures subsequently underwent OSR. There were no early deaths in either group. Periprocedural morbidity was 19% after OSR and 4% in the EVR group. Six early surgical graft failures were successfully treated with surgical revision; one restenosis after EVR was restented. During a mean follow-up of 4.1 years (range, 0.1-17.5 years) after OSR, 11 patients underwent 18 secondary interventions. Mean follow-up after EVR was 2.2 years (range, 0.2-6.4 years), and nine patients underwent 21 secondary EVR interventions. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were, respectively, 45%, 68%, and 75% at 3 and 5 years. Primary, assisted primary and secondary patency rates after EVR were 44%, 96%, and 96% at 3 years. Assisted primary patency was significantly higher in vein grafts than in ePTFE grafts (P = .05). Assisted primary and secondary patency was significantly higher in patients undergoing stenting compared with PTA (P = .02). At last follow-up, 93% of patients in both OSR and EVR groups had significant relief from symptoms. CONCLUSIONS: OSR of benign SVC syndrome is effective, with durable long-term relief from symptoms. EVR is less invasive but equally effective in the mid-term, albeit at the cost of multiple secondary interventions, and is an appropriate primary treatment for benign SVC syndrome. OSR remains an excellent choice for patients who are not suitable for EVR or in whom the EVR fails.