Author + information
Patient initials or identifier number
001xx04xxA Mr. Lin
Relevant clinical history and physical exam
Mr. L, a 50year-old male patient has past history of alcoholic liver cirrhosis in stage C (Child-Pugh classification). He received a peritoneovenous shunt (Denver shunt) for refractory as cites for 4 years. In recent 4 months, he suffered from progressive swelling of the face and bilateral upper arms, dyspnea on exertion, and increasing girth of waist The chest CT scan revealed a huge thrombus that caused complete obstruction of SVC and Denver shunt. However, anticoagulation therapy failed.
Relevant test results prior to catheterization
The contrast-enhanced chest computed tomography revealed that a huge thrombus had caused complete obstruction of thesuperior vena cava, which also involved the tip of the Denver catheter; the result was the malfunction of the peritoneovenous shunt and blood drainage of the upper venous system through the azygous and collateral veins. With the diagnosis of SVC syndrome.
Relevant catheterization findings
An approach from right femoral vein with Jukins Right 4/6Fr guiding catheter and it advanced to the proximal site of the lesion. The lesion successfully crossed by a Miracle 6 guide wire(AsahiIntecc, Aichi, Japan) supported by a 1.25 x 20 mm over-the-wire balloon catheter,and the lesion site was dilated by using a 4.0 x 20 mm balloon catheter. After dilation, an infusion catheter as Fountain was implanted.Thrombolytic therapy through the Fountain.
Two days later, the follow-up venography revealed some residual unresolved. Initially, in order to fix the Denver catheter, a 4.0 x 20 mm balloon anchored between the narrowing SVC and Denver catheter, and a Miracle 3 guide wire advanced to cross the occluded segment of the Denver catheter, distal injection through the 1.5 x 20 mm over-the-wire balloon confirmed the distal occlusion of the Denver catheter. Subsequently, in addition to sequential intra-catheter balloon dilations, the inner lumen was evacuated by pulling back an inflated 4.0 x 20 mm balloon. The contrast injection via the tip of the Denver catheter revealed a fast flow and confirmed the patency of the inner lumen. After this, the critical stenosis of the SVC and in nominate veins dilated with 12 x 40 mm and 14 x 40 mm balloons sequentially,which finally lead to full luminal expansion with less than 20% residual stenosis.
With the increasing use of indwelling venous catheters, such as dialysis catheters, and implantable cardiac pacemakers, these interventions have been proposed as the main “benign” cause of central venous thrombosis, stenosis, and total occlusion we have provided a valuable experience in dealing with catheter failure due to indwelling catheter-related SVC thrombosis and intra-catheter thrombosis. In addition to anti-coagulant therapy, endovascular intervention found to be an effective therapy for this condition with less trauma and more immediate symptomatic relief.