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Benign Superior Vena Cava Syndrome: Is Stenting The First Line Of Treatment?

Adnan Z. Rizvi, Manju Kalra, Haraldur Bjarnason, Wesam Moustafa, Thomas C. Bower, Audra A. Duncan, Enrique Sabater, Gustavo Oderich, William S. Harmsen, Cathy Schleck, Linda G. Canton, Peter Gloviczki.
Mayo Clinic, Rochester, MN.

OBJECTIVES: Endovascular therapy (EVT) has emerged as the first line of treatment for patients with superior vena cava (SVC) syndrome of benign etiology, but data on its durability remains scarce. This study evaluates the efficacy and durability of EVT and compares it to results of open surgical reconstruction (OSR).

METHODS: Clinical data from 70 consecutive patients, treated with EVT and OSR for benign SVC syndrome between November 1983 and June 2006 were retrospectively reviewed.

RESULTS: There were 30 males and 40 females (mean age, 43 years; range, 5 -75 years). Etiology included mediastinal fibrosis (n=31), indwelling catheters / pacemaker wires (n=34), idiopathic thrombosis (n=3), post-surgical thrombosis (n=2). Forty-two patients underwent OSR with 44 grafts via a median sternotomy using spiral saphenous vein (n=23), femoral vein (n=7), human allograft (n=1) or ePTFE (n=13). Fifteen OSRs followed failed endovascular interventions. Twenty-eight patients underwent primary EVT; balloon angioplasty (PTA, n=4), stenting (n=19), thrombolytic therapy with PTA (n=2) or stenting (n=3), with initial technical success in 100%. There were no early deaths or pulmonary embolism in either group. Four early graft failures underwent successful surgical revision. Over a mean follow-up of 4.3 years (range, 0.1-17.5 years) after OSR, 13 patients underwent 22 secondary interventions; 19 endovascular and 3 surgical. Primary, assisted primary and secondary patency rates of surgical bypass grafts were 72%, 80% and 82% at 2 years; 68%, 69% and 82% at 5 years. Mean follow-up after EVT was 2.0 years (range, 0.2-6.4 years);10 patients underwent 27 secondary endovascular interventions. Primary, assisted primary and secondary patency rates following EVT were 52%, 61% and 100% at 2 years. Primary patency at 2 years was significantly higher in the surgical group (p=0.03). At last follow-up 86% of OSR and 93% of EVT patients had significant relief from symptoms.

CONCLUSIONS: OSR of benign SVC syndrome is effective with durable long-term relief from symptoms. EVT is less invasive but equally effective in the mid-term, albeit at the cost of multiple secondary interventions. It has evolved as the primary treatment modality for benign SVC syndrome with OSR reserved for patients who are not suitable for, or who fail endovascular intervention.