Image-Guided Mechanical Thrombectomy Utilizing Penumbra Approach for Superior Vena Cava Syndrome as a Last Resort in Stage IV Lung Adenocarcinoma

Vivie Tran, Daniel Xue, Sachi Khemka, Hoang Ho, Mohammad M. Ansari, MD

PAD Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, TX, USA

Introduction

Superior Vena Cava Syndrome (SVCS) manifests as a constellation of signs and symptoms resulting from a mechanical obstruction of the SVC. This obstruction may occur suddenly or gradually, with malignancy and leads representing the primary culprit in a majority of cases. The typical scenario involves masses in the vicinity of the SVC exerting external pressure, resulting in the redirection of blood flow through collateral pathways. This condition results in impaired blood flow and venous drainage from the upper body, leading to symptoms such as facial and upper extremity swelling and dyspnea. Management includes radiation/chemotherapy, and stenting procedures, aiming to improve venous flow and alleviate respiratory compromise. We present a case of severe SVCS treated successfully with image-guided mechanical thrombectomy utilizing Penumbra.

Case Presentation

Female age 64, with PMH of stage IV lung cancer and COPD, presented with SVCS described as face, neck, and upper extremity swelling over one week. Pulmonary venogram showed a thrombus involving the bilateral innominate, subclavian, and axillary veins. After reviewing the images, decision was made to proceed with mechanical aspiration thrombectomy of the SVC, IVC, IJ, and innominate veins with a Penumbra Indigo System. After sequential balloon venoplasties, SVC venogram showed good flow through the proximal bilateral innominate veins with improved luminal gain in the SVC. Due to concerns regarding stent thrombosis, migration, and rupture, the SVC was not stented. The patient left in stable condition and reported doing well on follow-up.

Conclusion

Our case highlights the successful resolution of profound thrombosis in a patient with SVCS. Medical management predominantly focuses on addressing the underlying cause of SVC compression, often entailing interventions such as radiation, chemotherapy, or recanalization with a stent. Notably, our findings suggest that mechanical thrombectomy may be a potentially safe, feasible, and effective approach when compared to stenting in certain scenarios.