case_images: PMC5790922_01
case_images: Digital subtraction phlebography from the left (A) and right (B) subclavian veins showed superior vena cava and both the right and left brachiocephalic vein stenosis with collateral channels.
case_images: fsurg-05-00004-g001.jpg
case_images: PMC5790922_01_fsurg-05-00004-g001.jpg
case_images: F1
case_images: Results showed a large filling defect of the SVC and left BCV stenosis with the presence of collateral veins (Figure 1A). A 45-cm long six-French introducer sheath was inserted and a phlebography was performed, revealing a subtotal stenosis of the right BCV in its central two-thirds with multiple collateral channels (Figure 1B).
case_images: (A) In an attempt to preserve the central venous catheter (CVC) for further chemotherapy, the CVC tip was removed before stenting from the superior vena cava into the right subclavian vein using a trifoil EN-snare from access through the basilic vein. (B) Bilateral kissing stents deployment (a 14-mm nominal diameter and 150- and 100-mm nominal lengths, Sinus-XL Flex, Optimed) and (C) balloon angioplasty (an 8-mm diameter balloon within the right stent, a 10-mm diameter balloon within the left stent) of superior vena cava (SVC) and the bilateral caudal portion of the brachiocephalic veins were performed. (D) Using a snare-loop technique, the CVC tip was removed in the SVC within the stent to facilitate subsequent chemotherapy.
case_images: fsurg-05-00004-g002.jpg
case_images: PMC5790922_01_fsurg-05-00004-g002.jpg
case_images: F2
case_images: CVC was snared and withdrawn into the right subclavian vein using a trifoil EN-snare (Merit Medical, South Jordan, USA) through a right basilic vein access (Figure 2A). Conventional percutaneous balloon angioplasty of the left BCV and SVC with a 4-mm diameter balloon was performed first (Passeo  35, Biotronik, Berlin, Germany). Bilateral kissing self-expandable Sinus-XL Flex stents (Optimed, Ettlingen, Germany) were deployed from the left BCV vein to the SVC (a 14-mm nominal diameter and 150 mm in length) and from the right BCV to the SVC (a 14-mm nominal diameter and 100 mm in length) (Figure 2B). Kissing balloon angioplasty was then performed within the stents using a 10-mm diameter balloon (Armada  35, Abbott Vascular, Chicago, USA) into the left-sided stent and an 8-mm diameter balloon (Armada  35, Abbott Vascular) into the right-sided stent (Figure 2C).
case_images: Left (A) and right (B) subclavian venograms obtained after stents placement showed restoration of superior vena cava and both brachiocephalic veins patency without collateral channels. No significant residual stenosis was observed within the stents.
case_images: fsurg-05-00004-g003.jpg
case_images: PMC5790922_01_fsurg-05-00004-g003.jpg
case_images: F3
case_images: A 3-month follow-up computed tomography (axial sections and coronal section in maximum intensity projection) demonstrated bilateral stents patency without collateral veins. The left-sided stent, which ensures head and neck venous drainage, had a larger expansion than the right-sided one.
case_images: fsurg-05-00004-g004.jpg
case_images: PMC5790922_01_fsurg-05-00004-g004.jpg
case_images: F4
case_images: CVC was observed. CT venography showed stents expansion and patency with no collateral drainage (Figure 4).