SVC Occlusion–A Challenging Case of Recurrent Stenosis and Bailout Endovascular Stenting

Abstract

Background: Superior Vena Cava Syndrome (SVC) results from impaired venous return to the right heart, commonly due to malignancy. We present a unique case of SVC occlusion caused by dialysis-related catheter use and external rib compression. Case: A 44-year-old female with end-stage renal disease post-renal transplant and subsequent failure on dialysis via the subclavian vein developed orthopnea, dyspnea, and facial/chest wall swelling. CT venogram confirmed SVC syndrome due to chronic scarring and complete SVC occlusion. After multiple failed endovascular interventions at another institution, she was referred for central venous bypass. Following multidisciplinary evaluation, she underwent SVC stenting with two Viabahn stents, but symptoms persisted. A follow-up CT venogram revealed focal narrowing at the confluence of the internal jugular (IJ), innominate, and subclavian veins due to first rib compression. Rib resection was advised but declined, prompting a second-opinion evaluation. After reviewing prior imaging, a bailout venous intervention was performed. Using femoral, brachial, and IJ vein access, two kissing balloon inflations were done, followed by stenting with an 18 × 90 mm Wallstent. IJ and innominate veins were further dilated, improving luminal area and providing symptomatic relief. Conclusion: SVC syndrome can cause severe venous obstruction. While venous bypass and rib resection may be necessary in refractory cases, this case highlights the role of advanced imaging-guided endovascular intervention in managing complex, treatment-resistant SVC occlusion.