Endovascular Treatment of Vena Cava Occlusion

Clinical Presentation

Patients with chronic vena cava occlusion develop networks of deep and superficial venous collaterals, which are unable to respond to hemodynamic demands of changes in posture or physical activity with the same efficiency of the large-caliber vena cava. In fact, some of these venous collaterals may be physically compromised when the patient bends over in the course of daily activities, such as to tie a shoe or retrieve something from the floor.

Patients with congenital vena cava occlusion often adopt sedentary lifestyles or preferences for entertainment and exercise that are compatible with their blunted venous return. Commonly the vena cava occlusion is so subtle in onset and gradual in development that the patient's accommodation of physical limitations is imperceptible and must be elicited with specific questions during the clinical interview. Symptoms of superior vena cava occlusion such as fullness of the tongue or changes in color perception might only be recognized when they are suddenly relieved, following successful recanalization.

Generally, the entire constellation of symptoms is cumulatively a great burden to the patients, and most are eager for relief. The issue of elective recanalization of congenital IVC occlusion is less straightforward. Indications for treatment in our experience include need for IVC access, such as radiofrequency (RF) ablation for atrial fibrillation or relief of outflow obstruction in the setting of lower extremity DVT.

Imaging Evaluation

Cross-sectional imaging of the neck and chest in instances of SVC occlusion and of the abdomen and pelvis in instances of IVC occlusion should be a part of every elective recanalization. Intravenous contrast allows demonstration of every major vessel conducting hemodynamically significant blood flow and identifies the potential target inflow and outflow channels. Cross-sectional imaging also demonstrates areas of critical anatomy to be avoided during recanalization procedures, including the subclavian and innominate arteries in the upper chest; the aorta and right pulmonary artery near the cavoatrial junction; and the right renal artery, duodenum, and iliac arteries in the abdomen and pelvis. Cross-sectional imaging demonstrates venous segments containing contrast. Anatomically patent segments no longer conducting flow because of downstream occlusion and upstream collaterals may be overlooked. Transcutaneous ultrasound with compression is a valuable imaging adjunct in the groin and is useful for exploring the confluence of great saphenous, femoral, and deep femoral veins.