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Wednesday, November 28, 2018

Para-Axial Central Venous Stent Placement in Patients with Malignant Central Venous Obstruction with a Venous Port 


Summary


Endovascular central venous stent (CVS) placement has been shown to improve symptoms and outcomes related to central venous obstruction. In patients with malignant central venous obstruction, preservation of previously placed indwelling port catheters is an important consideration during CVS placement. Previously, catheters were removed during CVS placement and replaced within the stent lumen to achieve an intra-stent configuration (i-CVS). This prospective cohort study explores the option of para-axial stent placement (p-CVS) which would obviate the need for removal and replacement of the port catheter. A total of 61 patients with malignant central venous obstruction were included in the study, of which 38 underwent p-CVS and 23 underwent i-CVS. Patients who had previously placed implanted port catheters underwent p-CVS placement. i-CVS placement was performed in all patients who had stents placed prior to port catheter placement. The authors defined successful stent and catheter placement as deployment of the central venous stent without port dysfunction or residual central venous stenosis on completion venography. Follow up chest radiography was used to evaluate for catheter fracture or stent migration. At 6 month follow up, none of the patients suffered from catheter dysfunction/fracture or stent migration. Follow up CT imaging revealed in-stent stenosis in 6/24 of the p-CVS patients and 6/18 of the i-CVS patients, a statistically insignificant difference (p = 0.33).



Figure. (a, b) Transverse CT image and plain chest film show the i-CVS placement state. The catheter (arrow) of the implanted venous port is located in the lumen of the stent. (c, d) Transverse CT image and plain chest film show the p-CVS placement. The catheter (arrow) of the implanted venous port is located between the stent and the vessel wall.

Commentary


The logistical challenges associated with placement of central venous stents in patients with previously placed port catheters have not been previously adequately addressed. Removal and re-implantation of central venous ports or repositioning of the catheter tip using a snare to achieve an intra-stent configuration exposes patients to increased complication risks and additional procedural costs. The authors propose an alternate solution of leaving the port catheter external to the lumen of the stent and were able to show no complications of stent migration or catheter dysfunction as a result of this configuration. The authors do not specifically comment on whether any dual-lumen catheters were used during the study but they do note that a limitation of the study was that small diameter ports were used during the study. Conceivably, use of larger diameter catheters such as dialysis catheters or even dual lumen ports during p-CVS placement could contribute to an increased rate of catheter dysfunction or stent migration. This question needs to be addressed in follow up studies to help determine whether this could be a viable option in patients with ESRD. Longer term follow up is also needed to assess for potential increased complications that could occur with p-CVS placement. Additionally, since only 1 of the para-axial port catheters had to be removed during the study, it is not currently known whether removal of these catheters is associated with increased rates of intra-procedural catheter fracture or stent migration. Nonetheless, this study provides substantial evidence that para-axial port placement in patients with central venous obstruction is a viable option.

Click here for abstract

Kim, Su Ho, et al. “Para-Axial Central Venous Stent Placement in Patients with Malignant Central Venous Obstruction with a Venous Port.” Journal of Vascular and Interventional Radiology, vol. 29, no. 11, Nov. 2018, pp. 1567–1570.

Post Author:
Shuaib Mohammad, MD
Department of Radiology
Wake Forest Baptist Medical Center
@WakeForest_IR

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