Hospital Pharmacy - November 2017 - 666

724893
letter2017

HPXXXX10.1177/0018578717724893Hospital PharmacyScalese et al

Letter to the Editor

Antithrombotic Therapy Post
Endovascular Stenting for Superior
Vena Cava Syndrome

Hospital Pharmacy
2017, Vol. 52(10) 666
© The Author(s) 2017
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DOI: 10.1177/0018578717724893
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Michael J. Scalese1, Sheena L. Hayes1, and Sara Lott1
Dear Editor,
Superior vena cava syndrome (SVCS) is a diverse clinical
condition characterized by the compression or obstruction of
the superior vena cava (SVC). The symptomatology of
SVCS stems from impaired venous return commonly including upper body edema, dyspnea, or orthopnea with progression to respiratory distress, convulsions, or cerebral edema if
left untreated.1 While the most common etiology is malignancy, endovascular angioplasty with stent placement is considered to be the first-line therapy for all origins of SVCS.2
The use of antithrombotic therapy in conjunction with endovascular stents, however, has been highly controversial.
Despite a limited robustness, the pertinent literature
reveals a dichotomy of potential antithrombotic therapies.
The thrombogenic nature of stent introduction suggests using
antiplatelet therapy can reduce platelet activation, aggregation, and stent thrombosis. However, the venous location of
stent deployment suggests anticoagulant therapy with a vitamin K antagonist (VKA) may be more favorable.2,3 Although
limited by their retrospective and descriptive nature, the largest studies to date provide insight into the role of antithrombotic therapies.4,5
In an evaluation of 208 SVCS stenting procedures,
Lanciego et al found no association with dipyridamole (P =
.321) or VKA therapy to mortality (P = .463).4 However, an
association with stent thrombosis and an increase in mortality was found regardless of antithrombotic choice (P =
.018).4 Antiplatelet medications may therefore be beneficial
by reducing stent thrombosis, though this was not explicitly
described by Lanciego et al.4 In a similar fashion, Fagedet et
al found no association with the use of aspirin 75 to 325 mg/
day (P = .69) or VKA (P = .76) on reoccurrence of SVCS in
a study of 164 consecutive SVCS stent recipients.5 Similar
results were also reported in smaller studies and case reports
which reported no impact on mortality.5-9 These reports do,
however, suggest that antiplatelet therapies may reduce stent
thrombosis in the acute setting.
Given the associated burden with VKA interactions, particularly with chemotherapeutics, and its associated monitoring or safety and efficacy, the utility of antiplatelet therapy is
compelling. The lack of difference in survival benefit with
anticoagulation therapy despite presumed superiority in a
venous system model leads us to conclude that antiplatelet
therapy may be appropriate in the absence of other compelling anticoagulation indications. Antiplatelet therapy likely

reduces thrombotic risk while having lower potential for
hemorrhage compared with VKAs.4,5

Conclusion
We recommend using short-term antiplatelet therapy with
aspirin 75 to 325 mg/day over anticoagulation in conjunction
with endovascular stenting for SVCS.
References
1.

Herscovici R, Szyper-kravitz M, Altman A, et al. Superior
vena cava syndrome-changing etiology in the third millennium. Lupus. 2012;21:93-96.
Rice TW, Rodriguez RM, Light RW. The superior vena cava
syndrome: clinical characteristics and evolving etiology.
Medicine. 2006;85:37-42.
Rumbaut RE, Thiagarajan P. Arterial, venous, and microvascular hemostasis/thrombosis. In: Granger DN, Granger
J, eds. Platelet-Vessel Wall Interactions in Hemostasis and
Thrombosis. San Rafael, CA: Morgan & Claypool Life
Sciences; 2010:35-42.
Lanciego C, Pangua C, Chacon 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.
Fagedet D, Thony F, Timsit JF, et al. Endovascular treatment
of malignant superior vena cava syndrome: results and predictive factors of clinical efficacy. Cardiovasc Intervent Radiol.
2013;36:140-149.
Gross CM, Kramer J, Waigand J, et al. Stent implantation
in patients with superior vena cava syndrome. AJR Am J
Roentgenol. 1997;169(2):429-432.
Monaco RG, Bertoni H, Pallota G, et al. Use of self-expanding
vascular endoprostheses in superior vena cava syndrome. Eur J
Cardiothorac Surg. 2003;24(2):208-211.
Marcy PY, Magne N, Bentolila F, et al. Superior vena cava
obstruction: is stenting necessary? Support Care Cancer.
2001;9(2):103-107.
Thony F, Moro D, Witmeyer P, et al. Endovascular treatment
of superior vena cava obstruction in patients with malignancies. Eur Radiol. 1999;9(5):965-971.

Auburn University Harrison School of Pharmacy, AL, USA

Corresponding Author:
Michael J. Scalese, Assistant Clinical Professor, Department of Pharmacy
Practice, Harrison School of Pharmacy, Auburn University, 650 Clinic
Drive, Room 2100, Auburn, Mobile AL 36688, USA.
Email: mjs0065@auburn.edu

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