Port-a-cath snaring to deploy SVC stent
A 43-year-old woman who had colon cancer presented because of a progressive swelling of her face and neck and arms, cyanosis and edema of both hands, and shortness of breath at rest for the last 5 days. She had been receiving subsequent adjuvant chemotherapy, which was administered through a porta-cath placed thorough right subclavian vein in superior vena cava (SVC). Initial diagnostic workup contained a computed tomography scan and DUS, which showed thrombosis of the SVC reaching from the caval confluence of the azygos vein to both brachiocephalic. Vascular compression by a tumor or lymphadenopathy and pulmonary embolism were ruled out.
We performed venography over the right basilic vein and confirmed the diagnosis of an occlusion of the SVC. We placed a multiple-side hole lysis catheter for local thrombolysis for 24 hours. Second-look phlebography on the next day further showed a high-grade residual stenosis of the SVC, which was associated with the tip position of the port-a-cath that had been placed through the right subclavian vein. To ensure unrestrained venous inflow and to prevent secondary SVC syndrome, we decided to perform percutaneous transluminal angioplasty and stenting of the lesion. However, to prevent jailing of the port-a-cath tube by stent placement to keep it functional in case of future chemotherapy and to avoid surgical removal and the need for reimplantation with subsequent risk of thrombosis progression during perioperative pausing of anticoagulation, endovascular repositioning of the port-a-cath tube before percutaneous transluminal angioplasty and stenting was considered in a first approach. Over an 10F sheath access in the right femoral vein the stenosis was passed using a 0.035-inch guidewire for ballooning and stenting of SVC. Afterward, a goose neck snare was inserted over a delivery catheter from right arm venous access and the tip of the port-a-cath was captured in the SVC and pulled back into the right brachiocephalic vein. Then, balloon angioplasty, stent implantation (sinus-XL, 18/60 mm), and post dilation were performed over a 10F sheath access in the right common femoral vein. After successful stent implantation, the snared catheter in right brachiocephalic vein was released and was placed within the SVC stent. Venography at the end of the examination showed an unrestricted venous inflow.