Figura 1. Figure 1. Diagnostic angiography. Right jugular vein access. Severe obstruction of the rig...

Figura 2. Figura 2. Extra-support guidewire positioned from the right femoral vein access. Pre-dilat...

Figura 3. Figure 4. Self-expanding stent deployment via left access. Figure 5. Post-dilation of th...

Figura 4. Figure 6. Final angiography showing adequate stent positioning and venous flow restoration...

Introduction

Superior vena cava obstruction results from an impaired venous return and presents clinically by means of congestive symptoms including dyspnea, facial edema, and jugular venous distension. Most cases are associated with malignancies, particularly small-cell lung carcinoma. In advanced disease, endovascular stenting is an effective palliative measure, offering rapid clinical improvement with a low complication profile1.

Clinical case

A 64-year-old man with a history of hypertension and heavy tobacco use was diagnosed in 2024 with small-cell lung carcinoma. He underwent chemotherapy with etoposide and cisplatin (4th cycle) while receiving symptomatic management with clonazepam and methylprednisolone. He presented with progressive dyspnea (NYHA functional class III–IV), periorbital edema, and upper body (cloak-distribution) edema. Physical examination revealed jugular venous distension and findings consistent with superior vena cava syndrome (SVCS). Admission laboratory values were within normal limits. Chest computed tomography was obtained as the initial imaging study. It showed a 24×14-mm nodular opacity in the right apical region, a mediastinal lymph node conglomerate, and bilateral pleural effusions (Figure 1). In order to achieve a conclusive diagnosis, upper cavography and central venous phlebography were performed so as to correlate CT findings. The anterioposterior projection for the diagnostic cavography via ultrasound-guided access of the right internal jugular vein showed severe obstruction of both brachiocephalic venous trunks and the superior vena cava (Figure 2). Given symptom severity and rapid progression, urgent palliative endovascular treatment by means of an angioplasty was indicated.

Treatment and angioplasty technique

The procedure was performed in the cath lab under light sedation with ultrasound guidance. Three venous access sites were planned: right femoral vein (9-Fr valved introducer) and bilateral axillary veins (a 6-Fr valved introducer each). 7500 IU of sodium heparin were administered. From the right femoral access, a Terumo 0.035-inch hydrophilic guidewire was advanced to the right brachiocephalic trunk. That guidewire was then exchanged for an Amplatz extra-support wire to provide greater working zone stability as the devices went upwards. Using a snare technique, the guidewire was captured and withdrawn through the right axillary access. Pre-dilation of the superior vena cava and right venous confluence obstruction area was performed using an Atlas™ Gold high-pressure balloon (12×40 mm). The first self-expanding nitinol Medtronic Abre™ stent, measuring 16×100 mm, was then deployed. Post-deployment angiography showed recoil at the right venous confluence, which improved significantly following post-dilation (Figure 3). Via the left axillary access, a Terumo 0.035-inch hydrophilic guidewire was then advanced to the distal inferior vena cava, crossing through the struts of the previously implanted stent. That guidewire was exchanged for an Amplatz wire and then withdrawn through the right femoral access using a snare. After, a second self-expanding nitinol Medtronic Abre™ stent, measuring 16×80 mm, was implanted, achieving the Y-stenting configuration. Post-dilation was then performed with a non-compliant balloon at the level of the superior vena cava and left venous confluence (Figures 4 and 5). Final angiographic control confirmed adequate stent expansion with no residual stenosis and immediate, effective restoration of venous flow, resulting in rapid symptomatic improvement (Figure 6).

Discussion

Superior vena cava syndrome is an oncologic emergency whose clinical impact depends primarily on the rapidity of onset. Neoplastic extrinsic obstruction is a common cause2. Endovascular treatment has been established as the preferred therapeutic approach, offering effective and rapid resolution with a low risk of complications. This strategy is associated with high technical success rates, near-immediate clinical improvement, and lower morbidity and mortality compared with surgical intervention3. Nevertheless, there are no firm guidelines clearly defining optimal syndrome management.

The Abre™ stent (Medtronic, Minneapolis, MN, USA) was selected during procedural planning based on obstruction severity and specific device characteristics. Its open-cell nitinol design allowed for the second stent to be easily advanced with high precision, while providing sufficient force to overcome the lesion and ensure luminal patency. Pre- and post-dilation with a high-pressure balloon were critical components of this technique. This strategy is justified by tumor tissue physiology and vascular elasticity: tumors typically have a firm consistency, predisposing to recoil or partial stent deformation after deployment. Balloon dilation therefore ensures greater technical durability and higher procedural success.

At procedure completion, all introducers were removed in the cath lab and compression dressings were applied. The patient was transferred to the intensive care unit for hemodynamic monitoring. During hospitalization, antithrombotic prophylaxis was maintained with sodium heparin. At discharge, single antiplatelet therapy with acetylsalicylic acid (100 mg/day) was prescribed, considering the absence of documented prior thrombosis and the hemorrhagic risk associated with the patient’s active malignancy4.

Angioplasty currently is an essential tool within the multidisciplinary management of oncology patients presenting with acute symptoms5. The Y-stenting technique used in this patient refers to the characteristic radiological configuration achieved by implanting two parallel stents within the superior vena cava and its confluent tributaries, ensuring adequate bilateral upper limb drainage. Available evidence on superior vena cava syndrome is based primarily on case reports and retrospective studies, with reported technical success rates exceeding 90%6. Over time, this technique has become established as an effective option for rapid symptom relief and venous flow restoration.

Conclusion

In this case, endovascular treatment of neoplastic superior vena cava syndrome was a safe, effective, and rapidly resolving palliative strategy. The Y-stenting technique, though infrequently employed due to its technical complexity, enables restoration of bilateral upper limb drainage and optimization of superior vena cava flow.

1. Lanciego C, Pangua C, Chacón JI, et al. Endovascular stenting as the first step in the overall management of malignant superior vena cava syndrome. AJR Am J Roentgenol. 2009;193:549–558

2. Aung EYS, Sriram KB, Patel S, et al. Endovascular stenting in superior vena cava syndrome: a systematic review and meta-analysis. Cardiovasc Intervent Radiol. 2022;45:1236–1254

3. Wright K, Pritchard-Jones K, Bown J, et al. Malignant superior vena cava syndrome: a scoping review. J Thorac Oncol. 2023;18:664–673.

4. Scalese MJ, et al. Antithrombotic therapy post-endovascular stenting for superior vena cava syndrome. J Vasc Interv Radiol. 2017;28(10):1433–1439

5. Nicholson AA, Ettles DF, Arnold A, Greenstone M, Dyet JF. Treatment of malignant superior vena cava obstruction: metal stents or radiation therapy. J Vasc Interv Radiol 1997;8:781-8

6. Guerrero-Macías S, García-Ruiz A, Sánchez-González J, et al. Outcomes in patients managed with an endovascular stent for malignant superior vena cava syndrome. J Vasc Interv Radiol. 2023;34:435–441.

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Y-stenting technique for the endovascular treatment of superior vena cava syndrome of neoplastic origin: endovascular approach as palliative therapy. Case report

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