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Fig. 1. Left axillary venogram demonstrates an implantable port in place, as well as a focal stenosis in the cephalad portion of the SVC. Case Reference No. CC-0998-04 A 26-year-old man with a history of sickle cell disease and indwelling portacath presented with neck and bilateral arm swelling. An upper extremity venogram (Fig. 1) revealed a focal web-like stenosis of the superior vena cava (SVC). Via a groin approach, the SVC stenosis was dilated with 14-mm x 4-cm balloon, yielding a suboptimal result. A Palmaz stent (Cordis, Inc.) was therefore mounted on a 15-mm x 4-cm PEMT balloon (Medi-tech, Inc., Watertown, MA) and deployment was attempted. The stent migrated off of the balloon as the balloon inflated from proximal to distal on its shaft, and onto the wire (Fig. 2). An attempt to retrieve the stent from the right internal jugular vein (IJV) approach with a 10-mm snare (Microvena, Inc.) was unsuccessful and resulted in right IJV thrombosis. Through the existing right groin access, a 6-F vanAndel catheter (Cook, Inc., Bloomington, IN) was advanced over the wire through the stent and a 15-mm snare advanced over the wire / vanAndel / stent combination. The stent was crimped onto the vanAndel catheter and pulled out of the right femoral vein in its entirety (Fig. 3). The SVC stenosis was redilated with a 16-mm Blue Max (Medi-tech, Inc.) and an acceptable result obtained (Fig. 4). The patient's symptoms resolved. Questions: 1) What are the preferred stent in these applications? What are the tradeoffs of greater radial force of balloon expandable stents vs. self expanding stents? |
Fig. 2. Palmaz stent has migrated from the deployment balloon in the SVC.
Fig. 3. A Palmaz stent is crimped onto a 6-F vanAndel catheter. The stent was then removed from the patient via the groin puncture site.
Fig 4. SVC following angioplasty with 16-mm balloon yields an acceptable result. | |
2) How do you size self-expanding stents at such lesions to prevent "watermelon-seed" forward or retrograde migrations? 3) Any other approaches for stent retreival? 4) Should we have proceeded and placed another tpye of stent? Related cases: | ||
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