Management of upper extremity central venous obstruction using interventional radiology

Upper extremity central vein stenosis/occlusion is responsible for significant morbidity. The objective of this report is to review our management using interventional radiological techniques and to determine the long-term clinical results. All radiological interventions for central vein stenosis/occlusion (n = 59) between July 1991 and July 1996 at our institution were reviewed. The interventions consisted of thrombolytic therapy alone in 10 cases, PTA in 40 cases (combined with initial thrombolytic therapy in 6 cases), and deployment of a venous stent in 9 cases. At follow-up, the cumulative success (patency and relief of symptoms) was determined (Kaplan-Meier method). The involved vein was the subclavian, axillary, or innominate (SUB-AX-INN) in 45 cases and the superior vena cava (SVC) in 14 cases. The etiology was secondary to an indwelling foreign body (catheter, pacemaker lead) in 53 cases (90%), and spontaneous in only 6 cases (10%). The average follow-up after intervention was 17.2 months, with a cumulative success of 70 +/- 7.5% at 2 years, with rapid decline thereafter. Analysis of the failure quantiles revealed that 25% failed by 17 months, 50% failed by 26.6 months, and 75% failed by 33.8 months. There were no subgroup differences (log-rank test) for stenosis versus occlusion (p = 0.526), SUB-AX-INN versus SVC (p = 0.744), or if the intervention was begun < 5 days versus > or =5 days after symptom onset (p = 0.240), or whether or not a stent was deployed (p = 0.893). Interventional radiological techniques should be considered when symptoms from upper extremity central vein stenosis/occlusion are severe and disabling, or when veno-access or maintenance of patency of an ipsilateral arteriovenous (A-V) access is necessary. These results suggest an acceptable short-to medium-term solution.