Central venous stenosis (CVS) is a common problem in patients with a long standing implanted central venous catheter or a compressing mediastinal mass and this can lead to a critical situation with facial and neck swelling, distended neck veins, headache due to cerebral edema, dyspnea and in severe cases stridor and mental changes (1). In this situation stenting of the affected venous vessels (superior vena cava [SVC], left brachiocephalic vein [LBV], right brachiocephalic vein [RBV] left/right internal jugular vein [LJV/RJV] and left/right subclavian vein [LSV/RSV]) via the endovascular approach is an effective treatment option (2). However, in-situ catheter-material such as port- or hemodialysis catheters pose the problem of catheter-fixation to the vessel wall and this is possibly followed by functional deficiency due to catheter compression or catheter defects caused by the expanded stent (3). Therefore, the catheter material may temporarily be removed before stent implantation. So far this procedure has only been described for the SVC (3-6).

In this case report we describe a complex procedure with an in situ port catheter which was temporarily repositioned for stent implantation in the SVC and LBV.

A 54 year-old male patient with a central bronchial carcinoma (UICC stage IIIb) was referred to our clinic with symptoms of CVS, including distended neck veins, plethora of the face and upper extremities and dyspnea, for palliative SVC stenting. He had undergone left-sided subclavian port implantation nine months before for chemotherapy with Cisplatin and Vinorelbin in combination with external beam radiotherapy. Since there was no sufficient response to the first-line therapy, the medication was replaced by second-line therapy with Gemzar and Navelbine. Because of tumor progression, his CVS symptoms were considered to be due to tumor-related SVC stenosis and the patient was referred to our hospital for SVC stenting. The RJV was punctured with an 18G needle and biplane diagnostic angiography revealed a compression of the SVC at the level of the tumor which was causing a high grade SVC stenosis (Fig. 1A, G). Thereafter, a 7 Fr-introducer sheath (Pinnacle Introducer sheath, Terumo, Tokyo, Japan) was inserted and additional diagnostic angiography of the LBV was performed: this showed a subtotal stenosis of the LBV in its central two-thirds (Fig. 1B, G). After repositioning the tip of the port-catheter into the RBV using a 15 mm Andra-snare (Angiopro, Speyer, Germany), a self-expandable stent (14 mm diameter; 40 mm length Sinus-Repo-stent, Optimed, Ettlingen, Germany) was placed in the SVC without prior balloon dilatation (Fig. 1C, H). Balloon dilation was performed after placement of the self expandable stent in the SVC using a 10 mm diameter, 40 mm length Fox balloon (Abbott Laboratories, Abbott Park, IL) (Fig. 1C, D). Thereafter, the LJV was punctured and a 7 Fr-introducer sheath (Terumo, Tokyo, Japan) was introduced (Fig. 1D). Using the same 15 mm Andra-snare, the port-catheter was repositioned in the distal part of the LBV and it was fixed there by keeping the loop-wire of the snare around the port catheter, while the catheter of the snare was removed (Fig. 1E, I). Then the LBV stenosis was crossed with a guide-wire via the same sheath while the loop wire remained in place and two stents (12 mm diameter/40 mm length, and 12 mm diameter/60 mm length, respectively, Sinusflex-Repo, Optimed, Ettlingen, Germany) were placed via the same introducer sheath in the LBV, extending from the SVC to the LBV after pre-ballooning the stenosis with a 8 mm diameter/40 mm length Fox balloon (Abbott Laboratories) (Fig. 1I). Finally, the snare's catheter was inserted again and the port catheter was repositioned through the newly implanted catheter into the SVC (Fig. 1F, J). After manual compression the introducer sheaths were removed. The signs of CVS regressed within a few hours and the patient was discharged the same day with markedly short- and midterm symptom relief. The patient died two months later due to tumor progression without any signs of CVS.

Central venous stenosis is a common problem in patients with mediastinal tumors and/or central venous catheters with an incidence of 11% to 50% depending on the catheter type and access route (6-8). Interestingly, catheter associated stenosis occurs more often in patients with a subclavian central venous access (42%) than in patients with an internal jugular venous access (10%). CVS is more often seen with left sided central venous catheters than with right sided central venous catheters, and this is possibly due to a longer and more tortuous course of the left-sided catheters through the LBV (9). The treatment of CVS using percutaneous transluminal angioplasty (PTA) and stenting is a well accepted technique with usually rapid symptom relief in these patients (2, 5, 8). The complications of this procedure, including rupture of the SVC or stent migration, are rare (2). An in situ central venous catheter is usually removed before stenting to prevent catheter fixation between the stent and the vessel wall with the associated risk of catheter dysfunction or catheter loss (3). To avoid catheter removal and the associated strain and risks of a new central venous puncture (e.g. bleeding, pneumothorax and air embolism) for the patient, a technique that allows stenting of the SVC without removal of central venous catheters has been proposed by several authors (5, 6).

In this case report we describe the combined stenting of the SVC and the LBV with an in-situ central-venous catheter in a patient with SVC stenosis due to bronchial cancer, which was treated with external beam radiation therapy and multiple courses of chemotherapy, and a second stenosis in the proximal two-thirds of the LBV in the presence of a central venous port catheter. Due to the coincidence of the stenosis and catheter position in the LBV, we suspected the LBV stenosis as being the result of catheter-related scarring (Fig. 1B, G). To prevent the removal of the central venous catheter, it has to first be dislocated in the RJV before SVC stent implantation (Fig. 1H). Thereafter, it was dislocated in the distal LBV using a snare (Fig. 1E, I). The removal of the snare-catheter while the central venous catheter was held in place with the snare-wire allowed the simultaneous introduction of the stents through the same 7 Fr sheath and this avoided another venous puncture and sheath insertion (Fig. 1F, I). Further, another angiographic control procedure of the central venous catheter could be avoided prior to repositioning because the central venous catheter was constantly fixed with the snare and it was ready to be advanced in its original position. This approach is on the one hand convenient for the experienced interventionalist and it is also convenient for the patient since no new central venous catheter has to be placed. Further, one venous puncture and sheath insertion were avoided by using one sheath for the snare and the stents, and this reduced the risk of pneumothorax, bleeding and air embolism. Additionally, this procedure is cost-effective compared to the standard procedure since no new port system has to be implanted.

The first introducer sheath was inserted in the RJV because of the known SVC stenosis. Due to the lack of proper preinterventional imaging, the LBV stenosis was discovered on the first diagnostic angiograms. In retrospect, the puncture of the RJV was not necessary since all the stent and snare insertions could have been performed via a single introducer sheath placed in the LBV, which highlights the value of adequate pre-interventional imaging, such as contrast-enhanced CT, for treatment planning. In contrast to the previous reports by Bovenschulte et al. (3) and Palmié et al. (4) we used an internal jugular venous access route instead of a femoral venous access route. This approach is known to reduce the rate of venous thrombosis and post-punctional infections (10). It also facilitated proximal catheter displacement.

In conclusion, SVC and LBV stenting in a patient with CVS while preserving existing ventral venous catheters is feasible via a single venous access. The procedure is safe and it improves the patient's quality of life, while omitting the need for a second intervention for central venous catheter re-insertion.