Benign superior vena cava syndrome: stenting is now the first line of treatment.
BACKGROUND
Endovascular repair (EVR) is emerging as first-line treatment for patients with superior vena cava (SVC) syndrome of benign etiology, but data on its durability remain scarce. The aims of this study were to assess the efficacy and durability of EVR and compare results of EVR with open surgical reconstruction (OSR).


METHODS
Data from 70 consecutive patients undergoing treatment for benign SVC syndrome between November 1983 and November 2006 were retrospectively reviewed.


RESULTS
There were 30 males and 40 females (mean age, 41 years; range, 5-75 years). Etiology included indwelling catheters or pacemaker wires in 35 patients, mediastinal fibrosis in 31, idiopathic thrombosis in 2, hypercoagulable disorder in 1, and postsurgical thrombosis in 1. In 42 patients, OSR was done through a median sternotomy: repair was with spiral saphenous vein in 22, expanded polytetrafluoroethylene (ePTFE) in 13, femoral vein grafts in 6, and human allograft in 1. Fifteen OSRs followed failed EVR interventions. EVR was attempted in 32 patients and was successful in 28 (88%): 19 had stenting, 14 had percutaneous transluminal balloon angioplasty (PTA), 2 had thrombolytic therapy with PTA, and 3 had stenting. All four technical failures subsequently underwent OSR. There were no early deaths in either group. Periprocedural morbidity was 19% after OSR and 4% in the EVR group. Six early surgical graft failures were successfully treated with surgical revision; one restenosis after EVR was restented. During a mean follow-up of 4.1 years (range, 0.1-17.5 years) after OSR, 11 patients underwent 18 secondary interventions. Mean follow-up after EVR was 2.2 years (range, 0.2-6.4 years), and nine patients underwent 21 secondary EVR interventions. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were, respectively, 45%, 68%, and 75% at 3 and 5 years. Primary, assisted primary and secondary patency rates after EVR were 44%, 96%, and 96% at 3 years. Assisted primary patency was significantly higher in vein grafts than in ePTFE grafts (P = .05). Assisted primary and secondary patency was significantly higher in patients undergoing stenting compared with PTA (P = .02). At last follow-up, 93% of patients in both OSR and EVR groups had significant relief from symptoms.


CONCLUSIONS
OSR of benign SVC syndrome is effective, with durable long-term relief from symptoms. EVR is less invasive but equally effective in the mid-term, albeit at the cost of multiple secondary interventions, and is an appropriate primary treatment for benign SVC syndrome. OSR remains an excellent choice for patients who are not suitable for EVR or in whom the EVR fails.
Rizvi
Adnan Z
AZ
Division of Vascular Surgery, Mayo Clinic, Rochester, MN 55905, USA.
Kalra
Manju
M
Bjarnason
Haraldur
H
Bower
Thomas C
TC
Schleck
Cathy
C
Gloviczki
Peter
P
D000293:Adolescent; D000328:Adult; D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D002648:Child; D002675:Child, Preschool; D005240:Feasibility Studies; D005260:Female; D005268:Femoral Vein / Q000637:transplantation*; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011138:Polytetrafluoroethylene; D011474:Prosthesis Design; D012189:Retrospective Studies; D018570:Risk Assessment; D012501:Saphenous Vein / Q000637:transplantation*; D015607:Stents; D013479:Superior Vena Cava Syndrome / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*
D011138:Polytetrafluoroethylene