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W3136363997 abstract "To the Editor: Superior vena cava (SVC) syndrome is an obstruction of the SVC caused by both benign and malignant causes.1 Malignant causes include both primary and metastatic cancers, and carries an especially poor prognosis when caused by malignancies of the lung and mediastinum. Patients can present with a variety of symptoms, including dyspnea, hemoptysis, hoarseness, and syncope; patients can be identified on exam by facial, chest, and arm edema, along with cyanosis.1 Treatment modalities include a combination of chemotherapy and radiation therapy, but for patients with symptoms refractory to this modality, endovascular stenting is considered.2 Unfortunately, various complications of endovascular stent placement exist, including thrombosis, migration, and fracture of the stent, along with the potential for pericardial tamponade and pulmonary emboli.2–4 However, the complication of stent erosion into the trachea has not been commonly reported. A 60-year-old gentleman with past medical history inclusive of myocardial infarction and tobacco abuse presented to the Emergency Department with chief complaint of hemoptysis and dyspnea. Bronchoscopic biopsy revealed keratinizing squamous cell carcinoma. At that time, computed tomography (CT) scan of the chest was significant for primary right upper lobe mass with mediastinal lymphadenopathy (Fig. 1A). Patient subsequently obtained repeat bronchoscopy, which was significant for tumor in the right mainstem bronchus. Patient underwent tumor debulking, which was complicated by tracheal perforation, which was contained (Fig. 1B). Patient completed a course of amoxicillin-clavulanic acid.FIGURE 1: A, Computed tomography scan demonstrating primary right upper lobe mass with lymphadenopathy. B, Bronchoscopy revealing contained tracheal perforation.As an outpatient, patient had repeat radio-oncologic CT scan obtained, which revealed containment of tracheal perforation. Patient was initiated on EBR (33 treatments for a total of 66 cGy) and carboplatin/paclitaxel. After 1 month, CT scan revealed resolution of tracheal tear. Unfortunately, chemotherapy was stopped after 5 cycles secondary to patient developing esophagitis and neutropenia. Three months after patient’s initial presentation to the hospital, he presented to an outside Emergency Department with complaints of facial, neck, and bilateral upper extremity edema. CT scan was significant for findings concerning for SVC obstruction (Fig. 2), and he subsequently underwent metallic stent placement, with extension from the SVC to the left innominate vein. Additional stent was placed in the right internal jugular vein with extension to the right innominate vein. Patient underwent local thrombolysis. Venography performed after displayed sluggish flow, and patient was subsequently initiated on clopidogrel, but was later switched to apixaban.FIGURE 2: Computed tomography scan revealing superior vena cava obstruction.After further 3 months, patient presented to the Emergency Department with chief complaint of hemoptysis, dyspnea, and encephalopathy. Patient was admitted directly to the ICU secondary to complaints of hypoxemia and hemoptysis. Upon arrival to the ICU, patient was noted to be hypotensive with systolic blood pressure <90 mm Hg, and he was initiated on norepinephrine drip. CT chest revealed air in the right brachiocephalic vein at the level of the SVC abutting the anterior tracheal wall, raising concern for fistulous connection (Fig. 3). Apixaban was discontinued, and patient underwent emergent bronchoscopy. Flexible bronchoscopy with moderate sedation displayed erosion of the SVC stent into the lower right trachea (Fig. 4 with green arrow) with further compression of the right mainstem bronchus (Fig. 4 with black arrow). No interventions were performed; patient opted for palliative care.FIGURE 3: Computed tomography scan demonstrating air in the brachiocephalic vein.FIGURE 4: Bronchoscopy displaying erosion of superior vena cava stent into right lower trachea (green arrow). Bronchoscopy displaying compression of right mainstem bronchus (black arrow).DISCUSSION Management of malignant SVC syndrome is varied and multifaceted, dependent on the initial presentation of the patient. For patients with life threatening symptoms, including airway compromise, treatment primarily involves emergent endovenous recanalization of vessel with stent placement, while nonemergent stent placement is preferred in stable patients to promote venous flow.2,4–6 In a select group of patients, including those with thymoma, thymic carcinoma, and residual germ cell tumor, surgical venous bypass can be considered.6 Additionally, in patients that fail initial stent placement, surgical measures of thrombectomy or bypass grafting with vein graft can be pursued.7 Complications after SVC stent placement are not infrequent, and exist in up to 10% of patients.8 Stent complications have been noted following insertion of both polytetrafluoroethylene covered stents (covered stents) and uncovered stents, particularly with decreased stent patency (due to in stent thrombosis) in the uncovered stent group.9 The most common complications that occur peri-procedurally include stent misplacement and thrombosis, which occur in 10% of patients. Stent migration is an additional complication, but is thought to occur primarily due to inaccurate sizing of stent. Anatomically, the SVC is covered by the pericardium, and hence distal migration of stents have been associated with cardiac tamponade and hemorrhagic pericardial effusion.10 However, in review of all English literature, no reports were found in relation to erosion of stent and perforation through the trachea. Perhaps this has occurred, but has not been reported, or has been reported in non-English literature. Our case raises important questions in regards to the bronchoscopic management of patients with SVC-trachea fistula, with focus primarily being on palliation of symptoms. Important concepts to consider include whether patients are candidates for airway stenting, if they are able to tolerate general anesthesia, and if they are able to tolerate rigid bronchsocopy. We report this case to suggest that in patients with malignant SVC obstruction who present to the hospital with hemoptysis after stent placement, stent erosion into the tracheobronchial tree should be considered on the differential diagnosis. Rahul Dasgupta, MD* Ehab Hussein, DO†,‡ Harsh Shah, MD§ Paresh Timbadia, MD†,‡ Asok Dasgupta, MD†,‡*Summa Health System, Akron†Mount Carmel East Hospital‡The James Cancer Center, OSU§Mount Carmel Medical Group Columbus, OH" @default.
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W3136363997 date "2021-03-24" @default.
W3136363997 modified "2023-09-29" @default.
W3136363997 title "Erosion of Superior Vena Caval Stent into Trachea, An Unusual Cause of Hemoptysis" @default.
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