Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
We presented a 61 year-old woman with stage IV lung adenocarcinoma, which diagnosed in November 2015. She had already received third line chemotherapy and palliative radiotherapy but disease progression was still noticed. She admitted in June 2016 due to chest pain in the upper right side for about one week. She also reported dyspnea and poor appetite. Physical examination on admission revealed right jugular vein engorgement and decreased breath sounds in the right lung.
Relevant test results prior to catheterization
The chest computed tomography found right hilar lung cancer with obstructive pneumonitis and mediastinal lymphadenopathy with vascular compression, which resulted in SVC stenosis. She underwent SVC stenting with three Wallstents (Boston Wallstent Iliac Delivery System 16 mm x 60 mm, 18 mm x 60 mm, 20 mm x 55 mm) from SVC to left subclavian vein on June 10, 2016. However, about 10 days later, neck swelling developed.
Relevant catheterization findings
Angiography revealed abundant stent thrombosis and some collaterals developed.
We inserted terumo wire to distal left subclavian vein via right femoral vein access. Direct stenting to occluded site with self-expanding stent (Boston P.STENTWALL RP 20 x 55) performed. Unfortunately, the stent which was surrounded by abundant thrombus wasn’t fully expanded and the terumo wire dislodged.Initially, we engaged ANL1 to proximal SVC and tried to pass Boston V-18 and Fielder FC into the under expanded stent. Nevertheless, wiring through three layers of stent was difficult and the support was poor. Finally, we engaged MP1 to the proximal site of the stent and passed Fielder FC through stent to left sub clavian vein successfully. We attempted to perform post-dilatation to the under expanded stent but we had difficulty in passing the balloon into the stent. Then, we anchored Boston V-18 at proximal SVC for better support and started to post dilate with small balloon (2.0 mm x 8 mm) to large balloon (10.0 mm x 40 mm) sequentially. An organized thrombus at proximal stent edge still noticed after sequential dilatation. We inflated the balloon (10.0 mm x 40 mm) to 16 atm and tried to drag the thrombus to right atrium but invain. Therefore, we deployed another stent from left sub clavian vein to SVC (BostonP. STENTWALL RP 22 x 45). The final angiography was good with limited residual thrombus and collaterals had diminished.
Direct self-expandable stent deployment should be avoided while the vessel lesion is composed of large thrombus burden. Unexpanded self-expandable stent is disastrous and it takes great patience and cautions in the following endovascular rescue. Sequential dilatation of the stent, starting from lower-profile balloon, is necessary larger balloon is not easy to advance into the over-the-wire self-expandable sent. The situation is even worse when using 0.035 wires, because there is less space for 0.035-system balloon to advance into the stent. Wire loss is another disaster. Re-wiring into the middle hole of the stent is difficult, but it is necessary and workable.