Using Fenestrated Stent to Increase the Flow of Extracorporeal Membrane Oxygenation of Superior Vena Cava Compression Syndrome

Abstract

Superior vena cava syndrome (SVCS) is an obstruction of the venous return through the superior vena cava (SVC) or any other significant branches. The obstruction may be external, like thoracic mass compressing the SVC, or internal, like thrombosis or tumor, which directly invades the SVC. Patients experiencing a medical emergency after being initially stabilized require treatment for SVCS, including endovenous recanalization and the implantation of an SVC stent to reduce the risk of abrupt respiratory arrest and death. A 54-year-old female presented from the university medical center with weight loss and solid food dysphagia for three months. Chest-CT scan showed a mediastinal mass of 10 x 9 x 8 cm. A transbronchial biopsy was attempted. The patient was arrested during the bronchoscopy lab procedure. Cardiopulmonary resuscitation (CPR) was initiated, and venoarterial-extracorporeal membrane oxygenation (VA-ECMO) was done through the right femoral artery cannula size 15 Fr due to the narrowing of the artery and the left femoral vein cannula size 23 Fr. During the night shift, the ECMO flow was hard to maintain with fluids, which was realized with the ECMO outflow volume issue. The next day, in the hybrid operating room, a fenestrated SVC stent was placed in the SVC, brachiocephalic, and internal jugular veins. The patient's hemodynamics improved post-stenting, especially ECMO outflow. This case illustrates that stenting in SVCS is a valid therapeutic option to increase the ECMO flow in this patient group.

Keywords: ecmo outflow due to svcs; endovascular stent therapy; fenestrated stent; increase flow of ecmo; mediastinal tumors; superior vena cava (svc) obstruction; superior vena cava (svc) syndrome; va-ecmo.

Figure 1. SVC stenosis and deployed stents under fluoroscopy

(A) Fluoroscopy showing SVC stenosis. (B) Redacted view of SVC fluoroscopy. (C) Balloon angioplasty of SVC stenosis under fluoroscopy. (D) Fenestrated stent placement in the SVC under fluoroscopy. (E) Stent deployed internal jugular. (F) Post-stenting image showing deployed brachiocephalic and internal jugular veins through fenestrations of the primary stent. SVC: Superior vena cava.