Recanalization of Left Subclavian Vein Total Occlusion Jailed by Superior Vena Cava Stent Using Culotte Stenting Technique With a Dedicated Venous Stent

J INVASIVE CARDIOL 2018;30(12):E152-E153.

Key words: cardiac imaging, Culotte stenting, in-stent restenosis, thoracic central vein obstruction

A 60-year-old woman with a history of end-stage renal failure on hemodialysis over right forearm arteriovenous fistula presented with recurrent left arm and facial swelling. She initially presented with facial swelling 2 years ago due to thoracic central vein obstruction (TCVO) secondary to central venous catheter placement. She was treated with balloon angioplasty and implantation of a 16 x 60 mm Wallstent (Boston Scientific) in the superior vena cava (SVC) jailing the left subclavian vein. 

In this episode, venography performed via 6 Fr sheath in the left internal jugular vein showed the previous SVC Wallstent jailing the ostium of the left brachiocephalic vein (BCV) causing total occlusion, with collateral drainage to the right-side venous system (Figure 1). An 0.018˝, 30 g Astato chronic total occlusion guidewire (Asahi Intecc) was used to cross the left BCV occlusion through the Wallstent strut into the SVC, snared and externalized through a 9 Fr right common femoral vein sheath to form a “flossing wire.” The Wallstent strut was progressively dilated with a 12 mm Conquest dilation balloon (Bard Peripheral Vascular) up to 20 atm, but there was significant recoil of the stent struts (Figure 2). A 14 x 60 mm, self-expanding, closed-cell, nitinol, dedicated venous Vici stent (Boston Scientific) was deployed in a culotte fashion through the Wallstent strut, landing proximally in the SVC and distally in the left BCV (Figure 3). The stent was postdilated with a 12 mm Conquest balloon. The final result was satisfactory, without significant stent recoil (Figure 4). The patient was given 1 month of clopidogrel. Hemodialysis over her right forearm arteriovenous fistula was smooth afterward. Her arm and facial swelling resolved and remained asymptomatic up to 15 months of follow-up.

Stenosis or occlusion of the TCV occurs in up to 50% of hemodialysis patients as a result of fibrosis from previous central venous catheter placement. Endovascular treatment with balloon angioplasty with or without stenting is indicated for the treatment of symptomatic TCVO of benign etiology, but is limited by high rates of restenosis and need for reintervention. This case demonstrates that the high radial strength of a dedicated nitinol venous stent is able to overcome recoil of the Wallstent struts to achieve good acute angiographic result and clinical efficacy.

From the Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted June 19, 2018. 

Address for correspondence: Wai Kin Chi, MBChB, Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F Clinical Science Building, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong SAR, China. Email: chiwaikin@gmail.com