Treatment of superior vena cava syndrome using AngioJet™ thrombectomy system

Abstract

Background: Superior vena cava syndrome is a relatively rare presentation in which diminished venous return to the heart produces congestion of the neck, face and upper extremities. Typically, a mediastinal mass produces external compression on the superior vena cava and reduces venous return. However, superior vena cava syndrome can present acutely in the setting of vena cava thrombosis. Multiple scoring systems are available to assist clinicians with appropriate timing of interventions for SVC syndrome. When specific criteria are met, endovascular intervention can be beneficial to patients to prevent rapid deterioration. Case presentation: A 75-year-old female with no significant past medical history presented to the emergency department with increased facial swelling, nausea and vomiting which began the night prior to presentation. The patient underwent a CT chest which revealed a 3.2 × 3.0 × 3.8 cm spiculated mass compressing the right main bronchus and right pulmonary artery. The patient was intubated and interventional radiology was consulted. The patient underwent venography which showed extensive thrombosis of the innominate veins. Rheolytic thrombectomy with AngioJet™ was performed to alleviate clot burden and minimize risk of secondary pulmonary embolism. Kissing stents were placed in the bilateral innominate veins to maintain patency after thrombectomy. After the procedure, the patient was successfully extubated and had near complete resolution of facial swelling approximately 12 h post procedure. A follow up venogram performed on post procedure day 4 showed patent bilateral subclavian, innominate, and internal jugular veins as well as a patent superior vena cava. Conclusions: Acute occlusion of superior vena cava can present with life threatening symptoms such as loss of airway. AngioJet™ thrombectomy is another tool available to interventional radiologists when a patient's clinical condition necessitates treatment.

Endovascular mechanical thrombectomy and stenting in a case of central vein thrombosis

“…The rheolytic thrombectomy system (Angiojet) was first approved in 1996 for AV fistula graft thrombectomy12 and now routinely used during the percutaneous coronary intervention13 14 and lower limb venous thrombosis 15. However, the literature about the use of rheolytic thrombectomy system for central vein thrombosis is scarce and remains an off label indication 16. The first successful use of this system to treat superior vena cava (SVC) syndrome was reported in a child after orthotopic heart transplant in year 2016 17.…”

“…The first successful use of this system to treat superior vena cava (SVC) syndrome was reported in a child after orthotopic heart transplant in year 2016 17. Ramjit et al described the successful use of rheolytic thrombectomy in SVC syndrome in a woman with lung malignancy in year 2019 16…”

“…17 Ramjit et al described the successful use of rheolytic thrombectomy in SVC syndrome in a woman with lung malignancy in year 2019. 16 The index case had marked improvement in thrombus load following mechanical thrombectomy, which further improved following 72 hours of heparin infusion. The CVS stenting is recommended for failed angioplasty, following suboptimal results of balloon angioplasty and for repeat interventions.…”

“…15 However, the literature about the use of rheolytic thrombectomy system for central vein thrombosis is scarce and remains an off label indication. 16 The first successful use of this system to treat superior vena cava (SVC) syndrome was reported in a child after orthotopic heart transplant in year 2016. 17 Ramjit et al described the successful use of rheolytic thrombectomy in SVC syndrome in a woman with lung malignancy in year 2019.…”

Superior vena cava syndrome

“…The presence of a thrombus should be anticipated, if SVCS is associated with central lines, dialysis access catheters, cardiac device wires, more acute onset of symptoms, and when intraluminal masses can easily be passed by the wire [modified according to 62]. Removal by thrombaspiration, thrombectomy, local thrombolysis via the central line, and/ or catheter-directed thrombolysis should be attempted in highly symptomatic patients while incomplete thrombosis or less symptomatic patients might be treated with anticoagulation alone [62][63][64][65][66]. Best results for catheter-directed thrombolysis were obtained when thrombolysis was started within 5 days [63].…”