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AJR 2002; 178:635-639
© American Roentgen Ray Society

Original Report

Hemodynamic Changes After Self-Expandable Metallic Stent Therapy for Vena Cava Syndrome

Takuji Yamagami1, Toshiyuki Nakamura, Takeharu Kato, Shigeharu Iida and Tsunehiko Nishimura

1 All authors: Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.

Received June 15, 2001; accepted after revision September 6, 2001.

 
Address correspondence to T. Yamagami.


Abstract
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 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
OBJECTIVE. We examined changes in hemodynamics after self-expandable metallic stent placement in the vena cava.

CONCLUSION. The rapid increase in venous return immediately after expandable metallic stent placement influenced the hemodynamics of the circulatory system.


Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Growth of malignant lesions surrounding the vena cava often results in stenosis or obstruction of the vena cava and symptoms of venous congestion, that is, vena cava syndrome. Self-expandable metallic stent placement in the vena cava at the site of such lesions is widely accepted as a means to improve the quality of life for patients with advanced malignant disease [1,2,3,4]. Although this treatment is performed widely, little is known about the physiologic changes after self-expandable metallic stent placement. However, rapid changes in hemodynamics after stent therapy have been implicated in the occurrence of serious complications [5, 6]. Thus, we undertook the present study to elucidate changes in hemodynamics after self-expandable metallic stent placement.


Materials and Methods
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 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Between March and December 2000, placement of a self-expandable metallic stent for malignant vena cava syndrome was performed at our institution in five patients (one woman, four men; age range, 50-77 years; mean age, 62.2 years). In four patients, the inferior vena cava was involved, and in one patient, the superior vena cava was involved. None of the patients had cardiac dysfunction. The cause of vena cava stenosis or occlusion was compression by lung cancer metastasis to a surrounding lymph node in the patient with superior vena cava syndrome. In the four patients who had inferior vena cava syndrome, the cause was compression by a circumferential tumor, including metastatic liver tumor from the colon (n = 2) and stomach (n = 1) and hepatocellular carcinoma (n = 1). No patient had IV tumor thrombi. All patients developed clinical symptoms, including severe edema of the upper (n = 1) or lower extremities (n = 4), the abdominal wall (n = 3) or thoracic wall (n = 1), marked swelling of the scrotum (n = 4) or face (n = 1), and massive ascites as revealed on sonography or CT (n = 3). The presence of stenosis or occlusion of the vena cava was based on enhanced CT images and confirmed by venography. Stenosis ranged from 50 to 100 mm (mean, 78.0 mm). Self-expandable metallic stent placement was performed after obtaining informed consent from each patient.

A modified Gianturco Z stent (So Ho Medi-tech, Seoul, Korea) was used, details of which are described elsewhere [7, 8]. Handcrafted stents were made from 0.018-inch stainless steel wire. The inferior vena cava stent was 25 mm long with an approximate diameter of 25-30 mm, and the superior vena cava stent was 20 mm long with an approximate diameter of 20 mm. We used an assembly of multiple stents connected in tandem [7,8,9].

Before stent placement, venography was performed from two percutaneously inserted catheters via the right and left subclavian vein with the tips at the right and left brachiocephalic vein or from one catheter inserted via the right femoral vein with its tip at the lower level of the inferior vena cava. After the position for stent placement was decided, a 12- or 14-French polytetrafluorethylene sheath introducer (Cook, Europe; Bjaeverskov, Denmark) was advanced via the right femoral vein into the affected area. The stent was placed at the target position using a blunt tipped dilator as a pusher. In two patients with severe and resistant stenosis or occlusion of the inferior vena cava, stent placement was performed following balloon angioplasty. The balloon for the angioplasty catheter (Cordis, Miami, FL) was 12 mm in diameter and 20 mm in length. If residual stenosis and a developed collateral were seen on venography obtained from the distal site of the self-expandable metallic stent, a second assembly of stents was additionally positioned. None of the patients required angioplasty after stent placement or had serious complications.

In all five patients, systemic hemodynamics were monitored with a 7-French balloon-tipped four-lumen Swan-Ganz catheter (Zeon Thermodilution catheter; Zeon, Tokyo, Japan) as follows: using the Swan-Ganz catheter [10], we measured vena caval pressure just distal to the site of stenosis and in the right atrium; pulmonary capillary wedge pressure; and cardiac output before, immediately after, and 24 hr after stent placement. We also measured cardiac output by the thermodilution technique [10,11,12,13] with 10 mL of an iced 5% solution of dextrose in water.

We investigated the following parameters: improvement in clinical symptoms, change in urine volume 24 hr before and after stent placement, time course of the change in vena caval pressure just distal to the site of stenosis and in the right atrium, pressure gradient across the narrowed caval lesion (i.e., blood pressure between the vena cava distal to the narrowed lesion and the right atrium), pulmonary capillary wedge pressure, and cardiac output. Differences in 24-hr urine volume before and after stent placement and differences in each hemodynamic variable before and immediately after stent placement, as well as immediately after and 24 hr after stent placement, were statistically assessed by the paired t test.


Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Edema of the extremities in all patients, swelling of the scrotum in all patients with inferior vena cava syndrome, and swelling of the face in the patient with superior vena cava syndrome improved after treatment. Sonography or CT images showed a decrease in volume of ascites in the three patients with inferior vena cava syndrome who had massive ascites. Other symptoms also improved to some degree in all patients. Particularly, improvement in the patient with superior vena cava syndrome and in two of the four patients with inferior vena cava syndrome was such that their health was similar to that before the onset of vena cava syndrome.

The total 24-hr urine volume increased in all patients (Fig. 1). The mean increase of urine volume after stent placement was significant (p = 0.0010), from 1010.0 ± 151.7 mL (mean ± standard deviation [SD]; range, 800-1150 mL) to 2496.0 ± 414.1 mL (mean ± SD; range, 1920-2860 mL).



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  		Fig. 1. —Graph shows change in total 24-hr urine volume before and after self-expandable metallic stent placement.

 

The caval pressure just distal to the stenosis decreased in all patients after self-expandable metallic stent placement. In the patient with superior vena cava syndrome, the decrease was from 29 to 18 mm Hg, with a further decrease to 9 mm Hg after 24 hr. In the four patients with inferior vena cava syndrome, the mean value significantly decreased (p = 0.0170) from 25.3 ± 5.0 mm Hg (mean ± SD; range, 20-30 mm Hg) to 12.0 ± 4.3 mm Hg (mean ± SD; range, 8-18 mm Hg) just after stent placement. In these four patients, this decrease continued for 24 hr after stent placement (p = 0.1017). The mean distal inferior vena caval pressure after 24 hr was 6.3 ± 2.1 mm Hg (mean ± SD; range, 4-8 mm Hg).

Right atrial pressure after self-expandable metallic stent placement increased in all patients, with the mean pressure being significantly increased (p = 0.0008) from 3.6 ± 1.7 mm Hg (mean ± SD; range, 2-6 mm Hg) to 5.4 ± 1.3 mm Hg (mean ± SD; range, 4-7 mm Hg). Twenty-four hours after stent placement, in three (60%) of the five patients, the right atrial pressure value increased, whereas no change was noted in one patient and a decrease was noted in another (5.4 ± 2.6 mm Hg [mean ± SD; range, 1-7 mm Hg]).

The pressure gradient across the caval lesion decreased in all patients immediately after self-expandable metallic stent placement (Fig. 2). The mean value was significantly decreased (p = 0.0028) from 22.4 ± 5.3 mm Hg (mean ± SD; range, 16-28 mm Hg) to 7.8 ± 4.5 mm Hg (mean ± SD; range, 4-14 mm Hg). This decrease continued for 24 hr after stent placement (Fig. 2) but was not significant (p = 0.0506) at 1.4 ± 1.1 mm Hg (mean ± SD; range, 0-3 mm Hg).



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  		Fig. 2. —Graph shows change in pressure gradient cross caval lesion after self-expandable metallic stent placement.

 

Pulmonary capillary wedge pressure increased in all five patients immediately after stent placement and decreased in 80% of these patients after 24 hr (Fig. 3). The mean value increased (p = 0.0608) from 10.6 ± 3.4 mm Hg (mean ± SD; range, 6-14 mm Hg) to 13.0 ± 2.5 mm Hg (mean ± SD; range, 9-15 mm Hg) just after stent placement and decreased (p = 0.1778) 24 hr after stent placement (mean ± SD, 11.0 ± 4.1 mm Hg; range, 7-16 mm Hg).



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  		Fig. 3. —Graph shows change in pulmonary capillary wedge pressure after self-expandable metallic stent placement.

 

Cardiac output increased immediately after self-expandable metallic stent placement and then decreased 24 hr later in all five patients (Fig. 4). The mean initial increase was significant (p = 0.0032), from 5.69 ± 1.12 L/min (mean ± SD; range, 4.42-7.31 L/min) to 7.76 ± 1.11 L/min (mean ± SD; range, 6.46-9.22 L min), but was followed by a significant decrease (p = 0.0021) 24 hr after placement (mean ± SD, 6.16 ± 1.13 L/min; range, 5.14-7.58 L/min).



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  		Fig. 4. —Graph shows change in cardiac output after self-expandable metallic stent placement.

 


Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Most vena cava obstructions or stenoses cause marked distress. Superior vena cava syndrome is manifested by a headache that is exacerbated during changes of position, edema, and facial and neck pain, whereas inferior vena cava syndrome causes accumulated ascites and edema in the lower limbs, scrotum, and abdominal wall. Some vena cava strictures are caused by benign pathogenesis with various etiologies [1, 14,15,16,17,18,19], such as the introduction of catheters [16]. Such benign vena cava syndromes only occasionally necessitate treatment because of effective collateralization that compensates for central venous obstruction, with the result that the syndrome is not progressive [14,15,16]. Other vena cava strictures are caused by constriction or invasion of malignant lesions [1, 2, 4,5,6, 20] surrounding the vena cava. Such malignant lesions are already at an advanced stage in most patients and are thus unresectable. Hence, nonsurgical treatment such as radiation therapy [21, 22] or chemotherapy [23, 24] has been performed. However, with most of these therapies, a great deal of time is required to lessen the stenosis or obstruction and to relieve symptoms [21,22,23,24,25,26]; the expected effect also may not be obtained. Considering the quality of life for patients with advanced malignant lesions and their short life expectancy, a therapy that can achieve prompt relief is required.

In recent decades, self-expandable metalic stent therapy has been introduced as an effective method for relieving the stenosis of various canalized organs [27, 28]. Since the report by Charnsangavej et al. [9] in 1986, the benefits of the self-expandable metallic stent for vena cava stenosis have been widely acknowledged [1,2,3,4,5,6,7,8,9, 20, 25, 26]. The types of self-expandable metallic stents used have included traditionally handcrafted original or modified Gianturco Z stents [2, 6,7,8,9, 26]. Recently, commercially available self-expandable metallic stents have come into use [4, 29, 30]. It is well known that with the placement of such a stent in the narrowed area of the vena cava, prompt dilatation of the vascular lumen and correction of venous flow can be achieved, thus decreasing venous pressure distal to the stenosis and resulting in improvement of congestive symptoms [2]. Many reports cite relief of symptoms of malignant vena cava syndrome by self-expandable metallic stent placement until death or during a follow-up period in 90-100% of patients [1, 2, 4, 5, 20, 30,31,32,33].

Despite the widespread use of these stents, to the best of our knowledge, only a few reports have described hemodynamic changes after their placement. Kishi et al. [5, 20] measured changes in venous pressure just after such a stent placement. They reported decreased vena caval pressure distal to the stenosis in 100% of patients, with the mean value decreasing from 26.6 to 8.9 mm Hg in the superior vena cava [5] and from 27.7 to 14.7 cm H2O (20.4-10.8 mm Hg) in the inferior vena cava [20]. They found right atrial pressure to be minimally increased or unchanged in most patients. However, in one patient, the increase was as great as 8 cm H2O (5.9 mm Hg) after inferior vena cava stent placement [20]. The present study also showed a tendency similar to that found in previous research with regard to change in vena caval pressure distal to the stenosis and in the right atrium. The pressure gradient across the caval lesion decreased in all five patients immediately after self-expandable metallic stent placement, and the decrease continued even 24 hr after placement. These findings show the occurrence of delayed expansion of the stent and indicate that accompanying hemodynamic changes proceed at least up until 24 hr after stent placement.

An increase in venous return after relief of stenosis may be the reason for this response. This large change in hemodynamics caused by self-expandable metallic stent placement across the narrowed caval lesion can be appropriately considered to influence cardiac function. The increases in pulmonary capillary wedge pressure and cardiac output that were revealed after stent placement in all patients monitored by a Swan-Ganz catheter in our study may reflect an increase of preload for cardiac muscle accompanied by a rapid increase of centripetal venous inflow. If this assumption is acceptable, the cause of the previously reported complication of pulmonary edema [5] or that of heart failure [6] after self-expandable metallic stent placement for vena cava syndrome can be explained. All five patients in the present study had normal cardiac function. Hence, both pulmonary capillary wedge pressure and cardiac output increased as a result of an increase in centripetal venous return just after stent placement because left ventricular compliance was sufficiently retained. However, if these changes do not occur, it is suggested that sufficient left ventricular compliance may not be maintained. In these patients, the use of drugs such as diuretics and dopamine must be considered. Otherwise, when poor cardiac reserve is identified before stent therapy, it might be advantageous to consider an innovation in procedure, for example, using a stent with a smaller diameter or a balloon-expandable stent [1, 34] that is slowly dilated several different times. The decreased cardiac output 24 hr after stent placement in all five patients and the decreased pulmonary capillary wedge pressure in 80% (4/5) of the patients are presumed to result from decreased blood volume in the systemic circulation caused by increased urine output during the 24 hr after stent therapy.

The limitation of the present study lies mainly in the small number of patients. However, the change in each investigated hemodynamic parameter showed the same tendency in all or most of the evaluated patients. This finding suggests that these tendencies may commonly occur in such patients.

In conclusion, self-expandable metallic stent placement for refractory malignant vena cava syndrome is an effective therapy because of its ra;pid and reliable physiologic effect, reduced invasiveness, and contribution to the prognosis. However, the prompt increase in centripetal venous return after stent placement was shown to influence the hemodynamics of the circulatory system; thus, considerable attention must be given especially to patients with heart disease. Hemodynamic monitoring over time, for example, using a Swan-Ganz catheter, may be useful to prevent complications related to heart failure and pulmonary edema after self-expandable metallic stent placement.


References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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