Technical Considerations for Treatment of Malignant Superior Vena Cava Syndrome with an Inverted Aortic Endograft

Purpose: To describe the technique and technical challenges of off-label placement of an inverted unibody, bifurcated aortic endograft within an extrinsically compressed central venous lumen for the palliation of malignant superior vena cava (SVC) syndrome

Materials and Methods: This is a single-center retrospective review of seven patients who underwent stenting of the SVC and brachiocephalic veins for symptomatic malignant SVC syndrome from non–small cell lung cancer (NSCLC) using an inverted bifurcated aortic endograft (Endologix, Irvine, CA).

Results: From December 2016 to January 2019, 7 patients ages 48 to 72 years underwent endovascular central venous reconstruction for symptomatic malignant SVC syndrome. Patients had a diagnosis of stage IV NSCLC (n = 6) or stage IIIa NSCLC (n = 1) with varying degrees of clinically significant SVC syndrome. An inverted AFX2 aortic endograft was used for reconstruction, with the main body placed in the SVC and the iliac limbs extending into the bilateral brachiocephalic veins. Devices were deployed via a bilateral upper extremity venous access. There was one significant complication that involved fracture of the deployment catheter with subsequent graft migration into the right atrium during retrieval of the fractured nose cone. The migrated device was captured, repositioned, and secured in an iliac vein. Among the technically successful graft placements, four of six cases required ancillary techniques to aid in successful graft deployment. These techniques included balloon anchorage of the contralateral limb for graft seating, change in site of upper extremity venous access, and concurrent countertension of the contralateral graft. Additional steps were necessary predominantly because of extrinsic graft compression and the distance from extremity access to the culprit SVC lesion.

Conclusions: The use of an inverted unibody bifurcated aortic endograft is a therapeutic option for endovascular treatment of malignant SVC syndrome. The off-label use of this device in this anatomic context varies significantly from the on-label use in aortic aneurysmal disease and requires modifications in technique as a result.