Procedure: 

  1. Left internal jugular digital subtraction venography. 
  2. Left brachiocephalic angioplasty. 
  3. Left brachiocephalic stenting. 
  4. Left internal jugular embolectomy. 
  5. Postprocedural left internal jugular subtraction venography 
  6. Exchange of a left femoral Vas-Cath. 

Reason For Exam  : __ y/o Pt with central stenosis and SVC syndrome.  Needs stenting 

Indication: Dialysis dependent patient with history of multiple internal jugular catheters presenting with extensive facial and bilateral upper extremity edema. There is extensive laryngeal edema leading to the patient  being intubated.  The patient was referred for endovascular treatment of  SVC syndrome and exchange of a left sided femoral vascath due to a nonfunctioning catheter. 

 

Medications: 10 mg IV Versed; 8000 Units Heparin IV 

Contrast:  60 mL  non-ionic 

Fluoro time: 43.8 minutes 

Access site: Right common femoral vein with ultrasound 

Complications:  None immediate. 

 

Technique: 

The risks, benefits, and alternatives to the procedure and sedation were explained to the patients family.  The specific risks of bleeding, infection, and vascular injury were detailed and accepted. Written informed consent was obtained.  A time out/call to order was performed prior to procedure initiation. 

The patient presents with a nasotracheal intubation tube in place and was assessed for sedation and found to be an adequate candidate. A dedicated nurse monitored heart rate, blood pressure, and oxygen saturation throughout the procedure. A time out was performed prior to procedure initiation. The right and left neck as well as the right and left groins were prepped and draped in sterile fashion. 

 The vascular structures in the left neck were ultrasonographically evaluated. Images were stored and transferred to PACS.  Under ultrasound guidance, the left internal jugular vein was accessed with a micropuncture needle.  Vein patency and needle entry were documented. A 0.018″ wire was placed and the needle exchanged for a 5 French dilator. The inner stylet and 0.018 wire were then removed and digital subtraction venography was performed. 

 An Glidewire was advanced past the site of occlusion into the inferior vena cava, and the dilator exchanged for a 6 French sheath. A Kumpe catheter was advanced through the wire into the inferior vena cava and the Glidewire was then exchanged for an Amplatz guidewire. 

Attention was then directed to the left groin and access was obtained through a left femoral hemodialysis catheter. The indwelling heparin was aspirated and an Amplatz wire advanced to the level of the IVC. The existing dialysis catheter was then removed and a 16 French long sheath was advanced over the wire into the left femoral vein. The Amplatz wire was removed and an en snare tulip was used through the femoral access to snare the amplatz wire in the IVC to attain through and through access from the left internal jugular vein to the left femoral vein. 

The Ensnare was removed and a 5 French marking pigtail catheter was advanced over the wire from the left femoral vein to the left internal jugular vein and measurements were made.  The pigtail catheter was then removed and a 8 x 40 cm conquest balloon was utilized to angioplasty the occluded left brachiocephalic vein. 

Post angioplasty venogram through the left internal jugular vein demonstrated acute re-occlusion of the left brachiocephalic vein. The left brachiocephalic vein was then stented from the level of the SVC to the level of the left internal jugular vein utilizing a 14 x 80 mm Protege stent.  The stent was then sequentially angioplastied along its length up to a 14 x 40 mm.  The balloon was then removed and a glide catheter was advanced through the left femoral sheath into the left internal jugular vein above the level of the stent. 

Digital subtraction venography was performed. 

 The glide catheter was then removed and an 8 mm Fogarty balloon advanced over the wire. An embolectomy was performed. Digital subtraction venography through the left internal jugular vein sheath was then performed demonstrating tight stricturing of the proximal aspect of the stent. Multiple attempts were made to angioplasty the site of stricturing cephalad to the stent without success. 

 Subsequently a 8 x 2 Cutting Balloon was utilized to open the area of stricturing. Venography through the left internal jugular venous catheter was again performed demonstrating persistence of the stricturing. 

 A 14 x 40 mm conquest balloon was then advanced over the wire from the left femoral sheath up to the area of stricturing at the proximal aspect of the left brachycephalic stent and the cutting balloon was placed alongside the conquest balloon and both were inflated to a pressure of 5mm Hg. This process was repeated. The conquest balloon and cutting balloon were then removed and a straight 5F catheter advanced through the femoral access to the level of the left internal jugular vein.  Digital subtraction venography was performed.  The left internal jugular venous sheath and wire were then removed. 

 Attention was then turned to the groin and an Amplatz wire was passed through the catheter which was then removed along with the access sheath.  A new 20 cm Vas-Cath was advanced over the wire into the left femoral vein.  The wire was removed and  the ports were flushed and heparinized per protocol. The catheter was sutured in place and an antimicrobial disc and sterile dressing were applied. 

No immediate complication occurred, and the patient was discharged from the angiography suite in satisfactory condition. 

 

Findings: 

  1. Left internal jugular digital subtraction venography demonstrates complete occlusion of the left brachiocephalic/subclavian vein with multiple venous collaterals.
  1. Postprocedural left internal jugular subtraction venography demonstrates a widely patent left brachiocephalic stent.
  1. Exchange of a left femoral Vas-Cath. 

 

Impression: 

Successful angioplasty, thrombectomy and stenting of the left brachiocephalic vein with patent inflow from the left internal jugular vein to the SVC. 

 

Recommendation: 

High-dose intravenous heparin therapy should be maintained until the patient can be converted to Coumadin