Endovascular stenting in the management of malignant superior vena cava obstruction: comparing safety, effectiveness, and outcomes between primary stenting and salvage stenting

Abstract

Objective: To compare the safety, effectiveness, and outcomes of primary stenting and salvage stenting for malignant superior vena cava obstruction. Design: Case series with internal comparison.Setting: Regional hospital, Hong Kong. Patients:A total of 56 patients with malignant superior vena cava obstruction underwent 59 stentings from 1 May 1999 to 31 January 2014. Patients' characteristics, procedural details, and outcomes were retrospectively reviewed. Of the 56 patients, 33 had primary stenting before conventional therapy and 23 had salvage stenting after failure of conventional therapy. Statistical analyses were made by Fisher's exact test and Mann-Whitney U test.Results: Primary lung carcinoma was the most common cause of malignant superior vena cava obstruction (primary stenting, 22 patients; salvage stenting, 16 patients; P=0.768), followed by metastatic lymphadenopathy. Most patients had superior vena cava obstruction only (primary stenting, 16 patients; salvage stenting, 15 patients; P=0.633), followed by additional right brachiocephalic vein involvement. Wallstents (Boston Scientific, Natick [MA], US) were used in all patients. Technical success was achieved in all but two patients, one in each group (P=1.000). Only one stent placement was required in most patients (primary stenting, 28 patients; salvage stenting, 20 patients; P=0.726). Procedure time was comparable in both groups (mean time: primary stenting, 89 minutes; salvage stenting, 84 minutes; Endovascular stenting in the management of malignant superior vena cava obstruction: comparing safety, effectiveness, and outcomes between primary stenting and salvage stenting New knowledge added by this study • Endovascular stenting is safe and effective for relieving malignant superior vena cava obstruction (SVCO) in both primary stenting and salvage stenting settings.• Direct comparison between primary stenting and salvage stenting for safety, effectiveness, and outcomes of superior vena cava (SVC) stenting showed no significant differences in number of stents required, success rates, procedure times, symptom relief rates, complication rates, and re-procedure rates between the two groups. Implications for clinical practice or policy • Primary SVC stenting should be considered for patients at their initial presentation with SVCO before conventional therapy by radiotherapy and/or chemotherapy.• Salvage SVC stenting remains a safe and effective treatment for patients with SVCO after failure of radiotherapy and/or chemotherapy.

Double stent insertion for combined malignant airway and superior vena cava obstruction

“…Between 10% and 60% of patients with SVC obstructions exhibit SVC and bilateral brachiocephalic vein obstruction. [3,12,13] At the present case series, 2 patients (40%) presented with obstruction of SVC and bilateral brachiocephalic veins, and this result is comparable to the previous studies. [3,12,13] However, treatment of obstruction of SVC and bilateral brachiocephalic veins is not complicated, and unilateral stent insertion can achieve clinically successful outcomes.…”

“…These symptoms usually reduce patients’ quality of life for the remaining period of time during which they survive. [3,4] Patients with CMASO may have more serious illness condition than patients with only airway or SVC obstruction.…”

Endovascular Stenting in Superior Vena Cava Syndrome: A Systematic Review and Meta-analysis

“…Stenting has largely replaced radiation therapy as the first line procedure for managing malignant SVCS, due to its immediate nature, high success rate, and the retained possibility to attempt alternative therapies [4,10,12]. The only study to specifically examine the impact of stenting as a first-line procedure was a retrospective study of 56 malignant SVCS patients by Leung et al [41]. They found that patients who received stenting at initial presentation had significantly increased survival over patients who received stenting after the failure of traditional treatments, but found no significant difference in success rate, procedure time, symptom relief, complication rate or re-intervention rate.…”

“…Stenting was attempted as the first-line procedure for treatment of malignant SVCS in 4/54 studies, comprising 202 patients [17,20,22,40]. One further study retrospectively investigated a cohort of 56 malignant SVCS patients, with 33 patients undergoing stenting at initial presentation before chemoradiotherapy and 23 only after the failure of chemoradiotherapy [41]. Technical Success…”

“…The average mean survival was 4.71 months (SD = 1.4235), with a range of 2.49-6.70 months. One study found survival was significantly longer in patients in whom stenting was attempted as a first-line procedure [41]. Another study found survival was significantly longer in patients who underwent subsequent chemotherapy, or chemoradiotherapy, as compared to patients who did not receive further treatment [21].…”