Catheter-Directed Thrombolysis for Acute SVC Obstruction in a Patient with Metastatic Breast Cancer : Catheter-Directed Thrombolysis for SVC obstruction

Hailey Carroll; Fergal Dineen; Paul Ryan; Maeve Crowley; Stephen Power; Seamus O'Reilly

doi:10.32768/abc.202293407-410

Hailey Carroll ⁽¹⁾, Fergal Dineen ⁽²⁾, Paul Ryan ⁽³⁾, Maeve Crowley ⁽⁴⁾, Stephen Power ⁽⁵⁾, Seamus O'Reilly ⁽⁶⁾

(1) Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland, Ireland,

(2) Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland, Ireland,

(3) Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland, Ireland,

(4) Comprehensive Coagulation Centre, Cork University Hospital, Wilton, Cork, Ireland, Ireland,

(5) Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland, Ireland,

(6) Department of Medical Oncology, Cork University Hospital and Cancer Research at University College Cork, Cork, Ireland, Ireland

https://doi.org/10.32768/abc.202293407-410

Issue
Volume 9, Issue 3, August 2022

Submitted
February 28, 2022

Published
March 31, 2022

Keywords:

SVC obstruction, thrombolysis, metastatic breast cancer, port-a-cath, venous access device, anticoagulation, thromboembolism

PDF XML

Abstract

Background: External compression, thrombosis, or stenosis of the superior vena cava can lead to superior vena cava syndrome, a diagnosis that should be considered swiftly in patients presenting with classic symptoms such as facial and neck swelling, plethora, and distended neck veins.

Case Presentation: We report a case of acute port-a-cath associated superior vena cava thrombosis in a longstanding, previously uncomplicated vascular access device in a patient with stable ER+/PR+/HER2+ metastatic breast cancer. After initial treatment, there was limited clinical improvement with subcutaneous low molecular weight heparin (LMWH). Following multidisciplinary team discussion, catheter-directed thrombolysis was performed, which resulted in complete symptom resolution.

Conclusion: The recognition of signs and symptoms is crucial in diagnosing acute superior vena cava syndrome, particularly in patients with a malignancy history or a central venous access device in situ. The thrombotic complications of port-a-cath symptoms can occur at any time and management should be guided by multidisciplinary discussion. In appropriately selected patients, catheter-directed thrombolysis can be successful and can lead to rapid symptom resolution.

Full text article

Generated from XML file

References

Hinton J, Cerra-Franco A, Shiue K, Shea L, Aaron V, Billows G, et al. Superior vena cava syndrome in a patient with locally advanced lung cancer with good response to definitive chemoradiation: a case report. Journal of Medical Case Reports 2018; 12: 301. doi: 10.1186/s13256-018-1843-4.

Sekine I. A Prompt Diagnosis of Superior Vena Cava Obstruction Established by Physical Examination. Intern Med 2019; 58: 3211-3212. 2019/07/12. doi: 10.2169/internalmedicine.3151-19.

Klein-Weigel PF, Elitok S, Ruttloff A, Reinhold S, Nielitz J, Steindl J, et al. Superior vena cava syndrome. Vasa 2020; 49: 437-448. doi: 10.1024/0301-1526/a000908.

Farshidmehr P, Omrani Z, Cheraghali R. Totally implanted chemotherapy port catheters: literature review and report of four cases. Journal of Surgical Case Reports 2021; 2021. doi: 10.1093/jscr/rjab194.

Shaikh I, Berg K, Kman N. Thrombogenic catheter-associated superior vena cava syndrome. Case reports in emergency medicine 2013; 2013. doi: 10.1155/2013/793054.

Decousus H, Bourmaud A, Fournel P, Bertoletti L, Labruyère C, Presles E, et al. Cancer-associated thrombosis in patients with implanted ports: a prospective multicenter French cohort study (ONCOCIP). Blood 2018; 132: 707-716. 2018/07/08. doi: 10.1182/blood-2018-03-837153.

Machat S, Eisenhuber E, Pfarl G, Stübler J, Koelblinger C, Zacherl J, et al. Complications of central venous port systems: a pictorial review. Insights into Imaging 2019; 10: 86. doi: 10.1186/s13244-019-0770-2.

Walser EM. Venous Access Ports: Indications, Implantation Technique, Follow-Up, and Complications. CardioVascular and Interventional Radiology 2012; 35: 751-764. doi: 10.1007/s00270-011-0271-2.

Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 2020; 38: 496-520. 2019/08/06. doi: 10.1200/jco.19.01461.

Schutz JC, Patel AA, Clark TW, Solomon JA, Freiman DB, Tuite CM, et al. Relationship between chest port catheter tip position and port malfunction after interventional radiologic placement. J Vasc Interv Radiol 2004; 15: 581-587. 2004/06/05. doi: 10.1097/01.rvi.0000127890.47187.91.

Hernandez RK, Sørensen HT, Pedersen L, Jacobsen J, Lash TL. Tamoxifen treatment and risk of deep venous thrombosis and pulmonary embolism: a Danish population-based cohort study. Cancer 2009; 115: 4442-4449. 2009/07/02. doi: 10.1002/cncr.24508.

Debourdeau P, Espié M, Chevret S, Gligorov J, Elias A, Dupré PF, et al. Incidence, risk factors, and outcomes of central venous catheter-related thromboembolism in breast cancer patients: the CAVECCAS study. Cancer Med 2017; 6: 2732-2744. 2017/10/06. DOI: 10.1002/cam4.1201.

Straka C, Ying J, Kong F-M, et al. Review of evolving etiologies, implications and treatment strategies for the superior vena cava syndrome. SpringerPlus 2016; 5: 229. doi: 10.1186/s40064-016-1900-7.

Lacout A, Marcy PY, Thariat J, Lacombe P, El Hajjam M. Radio-anatomy of the superior vena cava syndrome and therapeutic orientations. Diagnostic and Interventional Imaging 2012; 93: 569-577. doi: 10.1016/j.diii.2012.03.025.

Kishi K, Sonomura T, Mitsuzane K, Nishida N, Yang RJ, Sato M, et al. Self-expandable metallic stent therapy for superior vena cava syndrome: clinical observations. Radiology 1993; 189: 531-535. doi: 10.1148/radiology.189.2.8210386.

Authors

Hailey Carroll

Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland

https://orcid.org/0000-0002-3052-3975

Fergal Dineen

Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland

https://orcid.org/0000-0002-9858-2218

Paul Ryan

Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland

https://orcid.org/0000-0002-3198-1257

Maeve Crowley

Comprehensive Coagulation Centre, Cork University Hospital, Wilton, Cork, Ireland

https://orcid.org/0000-0003-2245-1227

Stephen Power

Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland

https://orcid.org/0000-0001-6366-4048

Seamus O'Reilly

Department of Medical Oncology, Cork University Hospital and Cancer Research at University College Cork, Cork, Ireland

https://orcid.org/0000-0002-2887-7336

seamus.oreilly@hse.ie (Primary Contact)

Carroll H, Dineen F, Ryan P, Crowley M, Power S, O’Reilly S. Catheter-Directed Thrombolysis for Acute SVC Obstruction in a Patient with Metastatic Breast Cancer : Catheter-Directed Thrombolysis for SVC obstruction. Arch Breast Cancer [Internet]. 2022 Mar. 31 [cited 2024 Jul. 16];9(3):407-10. Available from: https://archbreastcancer.com/index.php/abc/article/view/542

Download Citation

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Copyright©. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International License, which permits copy and redistribution of the material in any medium or format or adapt, remix, transform, and build upon the material for any purpose, except for commercial purposes.

Most read articles by the same author(s)

Ruba A Hamed, Rachel J. Keogh, Abdullah Mohammed, Maria Twomey , Saif Almandhari , Deirdre O’Hanlon, Seamus O'Reilly, Primary Small Cell Carcinoma of the Breast: When a Rare Tumour is Real , Archives of Breast Cancer: Volume 10, Issue 3, August 2023
Aoife Broderick, Hailey Kathryn Carroll, Kenneth O'Riordan, Arthur Jackson , John Macfarlane , Seamus O'Reilly , Breeching “The Goldilocks Zone”: Tetraplegia as a Rare Life-Altering Infective Complication of Adjuvant Breast Cancer Chemotherapy , Archives of Breast Cancer: Vol. 10 No. 1 (2023): Volume 10, issue 1, February 2023

INTRODUCTION

Superior vena cava syndrome (SVCS) is a clinical condition due to obstruction of the superior vena cava (SVC) characterized by facial and upper extremity oedema and engorgement of neck veins, resulting in dyspnoea cyanosis collateralization of chest wall vessels, and is generally confirmed by cross-sectional imaging. 1 Superior vena cava obstruction (SVCO) is caused by external compression of the SVC by intrathoracic malignant disease, most commonly bronchogenic carcinoma or lymphoma. 2 Intrinsic stenosis or thrombosis of the SVC caused by central lines or medical devices can also result in SVC syndrome. 3 The increasing use of central venous access devices, such as port-a-cath systems, which are placed to facilitate long-term chemotherapy administration, has led to an increase in the number of patients diagnosed with superior vena cava syndrome. 4 5 6 Thrombotic complications of port-a-cath systems occur most commonly due to stenosis or occlusion of the host vein due to thrombus formation at the catheter tip, which more commonly occurs when the catheter tip is incorrectly positioned. 7 8

CASE PRESENTATION

A 39-year-old female with a history of de novo bone-limited oligometastatic triple-positive breast cancer, on maintenance trastuzumab, pertuzumab and tamoxifen since the completion of her initial chemotherapy in 2016, presented to the emergency department with a two-hour history of malaise with facial swelling and plethora. She had a right-sided porta-cath in situ, which was inserted at the time of her diagnosis to facilitate chemotherapy administration; the port-a-cath had been accessed without any problem two days ealier.

She was placed on bed rest in an upright position, and a urinary catheter was inserted to ensure minimal exertion. On examination, she appeared unwell, with significant facial plethora, periorbital and facial oedema, and distended neck veins. Based on her presentation and the severity of her symptoms, a clinical diagnosis of SVCO was made, and she was commenced on therapeutic tinzaparin at a dose of 175u/kg. 9 Her condition worsened with facial engorgement with increasing facial plethora ( Figure 1A). Due to her escalating symptoms, treatment was intensified, with a change of anticoagulation to twice daily enoxaparin at a 110% dose by weight, with a view to escalating care to a higher dependency ward to administer unfractionated heparin, in case of any clinical deterioration. Tamoxifen was stopped due to its pro-thrombotic properties.

There was no clinical improvement over the following 24 hours. Following multidisciplinary discussion, a decision was made to proceed with catheter-directed thrombolysis. Given the history of malignancy, a CT brain was performed to exclude intracranial metastases, which would contraindicate alteplase administration. Venography via the left brachial vein confirmed a large v olume of near occlusive thrombus within the left brachiocephalic vein and SVC (Figure 3). A thrombolysis catheter was positioned across the thrombus before catheterdirected thrombolysis with alteplase initiated at a rate of 1mg/hr. The following morning, there was a marked clinical and symptomatic improvement ( Figure 1B). A repeat venogram was performed, demonstrating complete resolution of the thrombus. Venography also revealed a narrowing at the left brachiocephalic/SVC junction, near the tip of the port-a-cath which responded to venoplasty (Figure 4). The remaining clinical course was uneventful, and the patient was discharged 72 hours later on therapeutic tinzaparin. The inciting factor for thrombosis was felt to be secondary to the positioning of the port-a-cath tip. Therefore, six weeks later, the chest wall pocket was opened, and the old port tubing was removed and a new longer tubing was inserted with the tip positioned at the cavo-atrial junction as she had an ongoing need for central access. Following this intervention, the patient was transitioned from tinzaparin to rivaroxaban and tamoxifen was resumed. She remains well on rivaroxaban and maintenance subcutaneous Herceptin and tamoxifen.

DISCUSSION

Patients with underlying malignancy are at higher risk of developing thrombotic complications. Here we discuss a patient with SVC obstruction secondary to port-a-cath related thrombosis, despite the uncomplicated use of port-a-cath for more than five years. Other contributing risk factors for our patient included obesity and tamoxifen use, although tamoxifen-associated VTE is more common in the first two years of therapy. 10 11 Patients presenting with SVCS generally have characteristic clinical findings on examination, which can vary in severity and duration. On examination, patients will most commonly have oedema of the face, neck, and/or upper extremities and collateralization of the veins in the neck or on the chest wall. Less common signs include plethora, cyanosis, dyspnoea, dysphagia, stridor, or neurological symptoms. 12 In acute SVC obstructions, patients present with a short history and more classic symptoms, such as in our patient's case. If the SVC obstruction has occurred over time, patients may have less severe signs and symptoms due to compensation from collateral vessels. In either scenario, signs and symptoms of cerebral oedema, laryngeal oedema, and haemodynamic compromise suggest a life-threatening or severe SVCS and should prompt immediate management. 13 14 While there are no consensus guidelines on managing venous device-associated thrombus and subsequent SVC syndrome, this case demonstrates catheter-directed thrombolysis's safety and clinical utility for port-a-cath related thrombosis in the appropriately selected patient. Multidisciplinary collaboration and discussion to balance bleeding and thrombotic risks led to the successful use of catheterdirected thrombolysis. Early detection of thrombosis is essential as thrombolysis produces higher success rates if carried out in the first five days following clot formation. 7

CONCLUSION

Venous thrombosis is a rare but well-recognized adverse event in patients with venous access devices and can lead to an acute or chronic presentation of superior vena cava syndrome. This case demonstrates that thrombotic complications of central venous access devices can develop at any time following insertion. Recognition of classic SVCO symptoms allows immediate and appropriate management, which is essential to limit morbidity. Catheterdirected thrombolysis can be safe and effective in appropriately selected patients with significant clinical symptoms. This case demonstrates that timely recognition and subsequent prompt intervention are vital to successful patient outcomes.

ETHICAL CONSIDERATION

Informed consent for publication was obtained from the patient.

Left). Facial oedema and plethora in keeping with clinical signs of SVCO Figure 1B (Right). Resolution of signs 24 hours after catheter-directed thrombolysisComputed tomography of the thorax demonstrated thrombus at the port tip with near-total occlusion of the superior vena cava and extension into the left brachiocephalic vein(Figure 2), with extensive collateralization in the left supraclavicular region. The tip of the port-a-cath was in a cranial position, with its tip in the mid-SVC. The optimal position for the tip of a port-a-cath is at the cavo-atrial junction or upper right atrium.10

Large volume thrombus within the SVC (short red arrow) with the port-a-cath tubing seen centrally within this thrombus (long white arrow)

Venography demonstrating thrombus within the left brachiocephalic vein extending into the SVC (white arrows). The tip of the port-a-cath (red arrow) is displaced cranially by the thrombus, sub-optimally located at the junction between the right brachiocephalic vein and the SVC.

Venography post 22 hours of thrombolysis demonstrating complete resolution of the thrombus. The tip of the port-a-cath (red arrow) is now positioned more caudally within the mid SVC. There is a stenosis in the cranial SVC (white arrow) which responded to venoplasty.

Read Counter : 557 Download : 62

Share Now

Catheter-Directed Thrombolysis for Acute SVC Obstruction in a Patient with Metastatic Breast Cancer Catheter-Directed Thrombolysis for SVC obstruction

Abstract

Full text article

References

Authors

Most read articles by the same author(s)

Important Links

Contact Info

Article Sidebar

Abstract

Full text article

References

Authors

Article Details

Most read articles by the same author(s)

Important Links

Contact Info