Central Venous Stenosis – Endovascular and Surgical Treatments

Introduction

The global incidence of subclavian, jugular, and femoral vein stenoses is 15.6%, 2.7% and 0-3.8%, respectively. Asymptomatic subclavian vein stenoses, detected by venograms, represent only 23-33% of all subclavian vein stenoses. Most reports show a higher incidence of asymptomatic versus symptomatic lesions: the rates of occurrence for subclavian vein stenoses are 41% versus 3.3%; the rates for nonsymptomatic jugular vein stenoses are 9% versus 1.6%.¹ Superior vena cava (SVC) syndromes are uncommon and usually caused by malignant diseases. In about 20% of the cases, however, the cause is benign. In addition to chronic mediastinitis, there are a growing number of reported cases of thrombosis resulting from endovenous devices (central catheters, pacemaker leads, etc.). Onset is often slow and insidious, with good tolerance in the early stages explained by the development of an effective collateral circulation.

While bilateral upper extremity venography is still the gold standard, currently computerized tomography and magnetic resonance imaging are more frequently used to make the diagnosis. Symptoms usually regress after medical treatment, sometimes requiring thrombolysis; however, in 10% of the patients, major functional impairment may require bypass surgery or transluminal angioplasty.² The surgical treatment of central venous stenosis has been reserved for either significantly symptomatic patients who have an obstruction or stenosis that is not amenable to an endovascular approach or for selected patients who have venous resection as part of a planned en block tumor resection.³ The etiology of central venous obstruction is usually extension of bronchopulmonary neoplasm or mediastinal disease. Stenosis or obstruction from venous thrombosis or fibrosis related to indwelling dialysis catheters, pace makers, defibrillators, or central venous lines is increasingly common.⁴