Editorial Type:
Article Category: Research Article
 | 
Online Publication Date: 01 Jun 2019

Sharp Recanalization of a Chronically Occluded Superior Vena Cava in a Patient with Multiple Prior Peripherally Inserted Central Catheters

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Page Range: 21 – 26
DOI: 10.2309/j.java.2019.002.001
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Abstract

Purpose: To present a unique case in which intravenous medications were administered intermittently through a peripherally inserted central catheter (PICC) line over 2 years in the presence of an occluded superior vena cava (SVC) due to impressive collateral development. However, SVC recanalization was ultimately needed to allow for long-term future access needs.

Case Description: This is a 25-year-old female with cystic fibrosis with known chronic occlusion of the SVC requiring multiple ports and PICC lines to maintain venous access. Despite conservative measures, it eventually became impossible to pass the occlusion via guidewire to properly place a PICC line. Sharp recanalization of the SVC occlusion with port placement was scheduled and successfully performed. The SVC was stented due to severe residual stenosis following recanalization and balloon angioplasty.

Results: Imaging revealed a significantly enlarged hemiazygos vein and numerous prominent collaterals throughout the mediastinum and chest wall, resulting in the majority of chest venous drainage entering the inferior vena cava. After recanalization, her SVC and port remained patent and functional.

Conclusions: For patients with SVC occlusion requiring venous access, a PICC line with the tip placed near the confluence of the brachiocephalic veins may serve as a temporary method for venous access in the presence of extensive collateral flow. However, for long-term access, sharp recanalization of the occlusion should be considered to restore normal laminar blood flow patterns and allow for optimum central venous catheter tip placement at the cavoatrial junction.

Keywords: sharp recanalization; chronically occluded SVC
Copyright: Copyright © 2019 Association for Vascular Access. All rights reserved.
Figure 1
Figure 1

Coronal CT showing increased prominence of the azygous (blue arrow) and right inferior phrenic vein (orange arrow).

Figure 2
Figure 2

Fluoroscopic image depicting 6-F Fogarty catheter (blue arrow) within the SVC remnant.

Figure 3
Figure 3

Digital subtraction angiography showing through-and-through access following sharp recanalization.

Figure 4
Figure 4

Balloon angioplasty across the SVC occlusion.

Figure 5
Figure 5

Digital subtraction angiography depicting substantial recoil of the occlusion following angioplasty.

Figure 6
Figure 6

Venogram following balloon angioplasty and stent placement across the SVC occlusion.

Figure 7
Figure 7

Chest x-ray showing port with port catheter tip extending below the SVC stent.

Contributor Notes

Correspondence concerning this article should be addressed to oshwaiki@neomed.edu
Received: 18 Sept 2018
Accepted: 28 Feb 2019
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