Acute Sinister in Stent Thrombosis in Endovascular Stenting in SVC Syndrome Secondary to Fibrosing Mediastinitis: Emergent Catheter-Directed Thrombolysis and Outcome—A Case Report

Abstract

A 40-year-old woman presented with a 4-week history of headache, facial swelling, and dyspnea. Computed tomography (CT) scan of the chest showed marked narrowing of the superior vena cava (SVC) with surrounding hypodense soft tissue and prominent collateral circulation in mediastinum, and the diagnosis of fibrosing mediastinitis was made. Biopsy suggested active fungal infection and she was treated with oral antifungal therapy. She reported persistent symptoms even after medical management; hence, she was taken for endovascular treatment with placement of a 16 × 60 mm stent (Optimed sinus-XL) in SVC. The patient complained of aggravation in symptoms immediately the next day, and a diagnostic venogram revealed acute total in-stent thrombosis. On an emergency basis, the patient was taken for catheter-directed thrombolysis (CDT) with tissue plasminogen activator (tPA) infusion. She was followed up with CT after1 year, which showed patent stent and no residual or recurrent thrombosis. She is on follow-up with marked relief in symptoms and improved quality of life. Catheter-directed thrombolysis is an emergent treatment modality with limited albeit growing evidence to treat acute in-stent thrombosis. CDT with tPA can be used to effectively treat acute thrombosis with promising results.

Keywords

• SVC syndrome
• fibrosing mediastinitis
• endovascular treatment
• in-stent thrombosis
• CDT