Physiologic Effect of Stent Therapy for Inferior Vena Cava Obstruction Due to Malignant Liver Tumor

  • Kazushi Kishi
  • Tetsuo Sonomura
  • Hisashi Fujimoto
  • Masashi Kimura
  • Katsuya Yamada
  • Morio Sato
  • Masanobu Juri



To understand systemic the influence of stent therapy for inferior vena cava (IVC) obstruction due to advanced liver tumor.


Seven patients with symptomatic IVC obstruction due to advanced primary (n = 4) or secondary (n = 3) liver tumor were subjected to stent therapy. Enrollment criteria included high IVC pressure over 15 mmHg and the presence of edema and ascites. Z-stents were deployed using coaxial sheath technique via femoral venous puncture. Physiologic and hematobiochemical parameters were analyzed.


All procedures were successful, and the stents remained patent until patient death. Promptly after stent placement, the IVC flow recovered, and the venous blood pressure in the IVC below the obstruction level showed a significant decrease from 20.8 ± 1.2 mmHg (mean ± SE) to 10.7 ± 0.7 mmHg (p < 0.01). Transient mild increase of right atrial pressure was observed in 1 patient. During the following week prominent diuresis was observed in all patients. Mean urine output volume in the 3 days before the stent therapy was 0.81 ± 0.09 l/day compared with 2.1 ± 0.2 l/day (p < 0.01) in the 3 days after. The edema and ascites decreased in all patients. The caval pressure change correlated well (r > 0.6) with the urine volume increase, and with the decreased volume of edema and ascites. The urine volume increase correlated well with the decrement of edema, but not with that of ascites. Improvements for various durations in the levels of blood urea nitrogen, serum creatinine, lactate dehydrogenase, fibrinogen, and platelet count were found (p < 0.05). These hematobiochemical changes were well correlated with each other and with the decrement of ascites. Two patients showed a low blood sodium level of 128.5 mEq/l after intensive natriuresis, and one of them died on day 21 with hepatic failure, which was interpreted as maladaptation aggravation. The mean survival time was 94.1 ± 34.1 days (mean ± SD), ranging from 21 to 140 days after stent treatment.


The stent therapy for IVC obstruction due to malignant liver tumors was followed by a series of physiologic and hematobiochemical consequences, most of them favorable but some possibly unfavorable. Rational interpretations and predictions of sequelae based on physiologic science including cardiology, hepatology, and nephrology would facilitate the best management of stent therapy for malignant IVC obstruction.


Ascites Edema Interventional procedures Obstruction Stenosis Stent Vena Cavae 


  1. 1.
    Entwisle KG, Watkinson AF, Hibbert J, Adam A (1995) The use of the Wallstent endovascular prosthesis in the treatment of malignant inferior vena cava obstruction. Clin Radiol 50:310–313PubMedGoogle Scholar
  2. 2.
    Kishi K, Sonomura T, Nishida N, Mitsuzane K, Kobayashi H, Juri M, et al (1994) Self-expandable metallic stent therapy for inferior vena cava obstruction secondary to malignancy: Clinical observations. Nippon Igaku Hoshasen Gakkai Zasshi 54:389–398PubMedGoogle Scholar
  3. 3.
    Ganong WF (1996) Dynamics of blood and lymph flow. In Ganong WF (ed) Review of medical physiology. 12th ed. Lange Medical Publishers, Las Altas, CA, pp 525–541Google Scholar
  4. 4.
    Sawada S, Fujiwara Y, Koyama T, Kobayashi M, Tanigawa N, Iwamiya T, et al (1992) Application of expandable metallic stents to the venous system. Acta Radiol 33:156–159PubMedCrossRefGoogle Scholar
  5. 5.
    Charnsangavej C, Carrasco CH, Wallace S, Wright KC, Ogawa K, Richli W, et al (1986) Stenosis of the vena cava: Preliminary assessment of treatment with expandable metallic stents. Radiology 161:295–298PubMedGoogle Scholar
  6. 6.
    Furui S, Sawada S, Irie T, Makita K, Yamauchi T, Kusano S, et al (1990) Hepatic inferior vena cava obstruction: Treatment of two types with Gianturco expandable metallic stents. Radiology 176:665–670PubMedGoogle Scholar
  7. 7.
    Paterson J, Rimmer T, Bowker A, Renwick I (1996) Stenting for inferior caval obstruction (letter). Palliative Med 10:344–345Google Scholar
  8. 8.
    Yamagami T, Nakamura T, Kato T, Iida S, Nishimura T (2002) Hemodynamic changes after self-expandable metallic stent therapy for vena cava syndrome. AJR Am J Roentgenol 178:635–639PubMedGoogle Scholar
  9. 9.
    Chacon Lopez-Muniz JI, Garcia Garcia L, Lanciego Perez C, Cruz Mora MA, Garcia Peris A, Martinez Martinez B, et al (1997) Treatment of superior and inferior vena cava syndromes of malignant cause with Wallstent catheter placed percutaneously. Am J Clin Oncol 20:293–297PubMedGoogle Scholar
  10. 10.
    Fletcher WS, Lakin PC, Pommier RF, Wilmarth T (1998) Results of treatment of inferior vena cava syndrome with expandable metallic stents. Arch Surg 133:935–938PubMedGoogle Scholar
  11. 11.
    Laing AD, Thomson KR, Vrazas JI (1998) Stenting in malignant and benign vena caval obstruction. Australas Radiol 42:313–317PubMedGoogle Scholar
  12. 12.
    Sato T, Itoh M, Ohta N, Motoyoshi A, Saito Z, Umezaki M (2001) Successful treatment for the IVC syndrome due to recurrence of colon cancer: Chemotherapy in combination with the use of the expandable metallic stent placement. Hepatogastroenterology 48:1048–1049PubMedGoogle Scholar
  13. 13.
    Oudkerk M, Heystraten FM, Stoter G (1993) Stenting in malignant vena caval obstruction. Cancer 71:142–146PubMedGoogle Scholar
  14. 14.
    Carrasco CH, Charnsangavej C, Wright KC, Wallace S, Gianturco C (1992) Use of the Gianturco self-expanding stent in stenoses of the superior and inferior venae cavae. J Vasc Interv Radiol 3:409–419PubMedGoogle Scholar
  15. 15.
    Altuntas B, Yarali N, Kuyucu S, Arslan Z, Ertan U, Erden A, et al (1997) Budd–Chiari syndrome in a child secondary to membranous obstruction of the hepatic vein treated by percutaneous transluminal angioplasty: Report of a case. Turk J Pediatr 39:551–555PubMedGoogle Scholar
  16. 16.
    Hirose A, Yoshioka K, Ono M, Yanagisawa T, Kamata H (1992) A case of pulmonary edema after stent therapy to inferior vena caval obstruction. In: 6th Meeting of the Metallic Stent Kenkyuukai, 1992, OsakaGoogle Scholar
  17. 17.
    Stanley P (1989) Budd–Chiari syndrome. Radiology 170:625–627PubMedGoogle Scholar
  18. 18.
    Kishi K, Sonomura T, Mitsuzane K, Nishida N, Yang RJ, Sato M, et al (1993) Self-expandable metallic stent therapy for superior vena cava syndrome: Clinical observations. Radiology 189:531–535PubMedGoogle Scholar
  19. 19.
    Sato M, Yamada R, Tsuji K, Kishi K, Terada M, Shioyama Y, et al (1990) Percutaneous transluminal angioplasty in segmental obstruction of the hepatic inferior vena cava: Long-term results. Cardiovasc Intervent Radiol 13:189–192PubMedGoogle Scholar
  20. 20.
    AJCC, Cancer AJCo (1997) AJCC cancer staging manual, 5th edn. Lippincott-Raven, PhiladelphiaGoogle Scholar
  21. 21.
    Japan LCSGo (1992) The general rules for the clinical and pathological study of primary liver cancer, 3rd edn. Kanehara Shuppan, TokyoGoogle Scholar
  22. 22.
    Yamada R, Kishi K, Sato M, Sonomura T, Nishida N, Tanaka K, et al (1995) Transcatheter arterial chemoembolization (TACE) in the treatment of unresectable liver cancer. World J Surg 19:795–800CrossRefPubMedGoogle Scholar
  23. 23.
    Kishi K, Sonomura T, Mitsuzane K, Nishida N, Kimura M, Satoh M, et al (1992) Time courses of PIVKA-II and AFP levels after hepatic artery embolization and hepatic artery infusion against hepatocellular carcinoma: Relation between the time course and tumor necrosis. Radiat Med 10:189–195PubMedGoogle Scholar
  24. 24.
    Furui S, Sawada S, Kuramoto K, Inoue Y, Irie T, Makita K, et al (1995) Gianturco stent placement in malignant caval obstruction: Analysis of factors for predicting the outcome. Radiology 195:147–152PubMedGoogle Scholar
  25. 25.
    Abaskaron M, Bisker J, Hayden T (1985) Computed tomographic demonstration of obstruction of the inferior vena cava caused by hepatocellular carcinoma. Comput Radiol 9:41–43CrossRefPubMedGoogle Scholar
  26. 26.
    Didier D, Racle A, Etievent JP, Weill F (1987) Tumor thrombus of the inferior vena cava secondary to malignant abdominal neoplasms: US and CT evaluation. Radiology 162:83–89PubMedGoogle Scholar
  27. 27.
    Mori H, Maeda H, Fukuda T, Miyake H, Aikawa H, Maeda T, et al (1989) Acute thrombosis of the inferior vena cava and hepatic veins in patients with Budd-Chiari syndrome: CT demonstration. AJR Am J Roentgenol 153:987–991PubMedGoogle Scholar
  28. 28.
    Pugh RNH, Murray-Lyon IM, Dawson JL, et al (1973) Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 60:649–659Google Scholar
  29. 29.
    Kishi K, Sonomura T, Mitsuzane K, Nishida N, Yang RJ, Nomura S, et al (1992) Expandable metallic stent therapy for SVC syndrome: Effects on local venous pressure, vascular diameter, symptoms, and these correlations. Nippon Igaku Hoshasen Gakkai Zasshi 52:1661–1670PubMedGoogle Scholar
  30. 30.
    Braunwald E (1992) Pathophysiology of heart failure. In: Braunwald E (ed) Heart disease, 4th edn. WB Saunders, Philadelphia, pp 393–418Google Scholar
  31. 31.
    Wright KC, Wallace S, Charnsangavej C, Carrasco CH, Gianturco C (1985) Percutaneous endovascular stents: An experimental evaluation. Radiology 156:69–72PubMedGoogle Scholar
  32. 32.
    Uchida BT, Putnam JS, Rosch J (1987) “Atraumatic” transjugular needle for portal vein puncture in swine. Radiology 163:580–581PubMedGoogle Scholar
  33. 33.
    Humphreys MH, Lin SY (1988) Peptide hormones and the regulation of sodium excretion. Hypertension 11:397–410PubMedGoogle Scholar
  34. 34.
    Althaus SJ, Perkins JD, Soltes G, Glickerman D (1996) Use of a Wallstent in successful treatment of IVC obstruction following liver transplantation. Transplantation 61:669–672PubMedGoogle Scholar
  35. 35.
    Maack T (1996) Role of atrial natriuretic factor in volume control. Kidney Int 49:1732–1737PubMedGoogle Scholar
  36. 36.
    Tacke J, Antonucci F, Stuckmann G, Mattias P, Espinosa N, Zollikofer CL (1994) The palliative treatment of venous stenoses in tumor patients with self-expanding vascular prostheses. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 160:433–440PubMedGoogle Scholar
  37. 37.
    Irving JD, Dondelinger RF, Reidy JF, Schild H, Dick R, Adam A, et al (1992) Gianturco self-expanding stents: Clinical experience in the vena cava and large veins. Cardiovasc Intervent Radiol 15:328–333PubMedGoogle Scholar
  38. 38.
    Schwarzenberg H, Link J, Muller-Hulsbeck S, Brossmann J, Palmie S, Schmid A, et al (1996) Therapy of venous stenosis using Wallstents. Dtsch Med Wochenschr 121:1383–1389PubMedGoogle Scholar
  39. 39.
    Rubin P, Casarett GW (1968) Skin and adnexa. In: Rubin P, Casarett GW (eds) Clinical radiation pathology. WB Saunders, Philadelphia, pp 62–91Google Scholar
  40. 40.
    Hayward SJ (1990) Portal venous collateral drainage in IVC obstruction. Clin Radiol 41:206–208PubMedGoogle Scholar
  41. 41.
    Nishida T, Okuda A (1991) Case report: Diagnosis of cavo-portal shunt in inferior vena cava obstruction: Comparison between venography and dynamic scintigraphy. Clin Radiol 43:274–275CrossRefPubMedGoogle Scholar
  42. 42.
    Akai S, Kanazawa S, Gochi A, Nakamura K, Yasui K, Hiraki Y, et al (1995) Asymptomatic membranous obstruction of the inferior vena cava due to large intrahepatic collaterals. Cardiovasc Intervent Radiol 18:403–405Google Scholar
  43. 43.
    Kendall B (1965) Collateral flow to the portal system in obstruction of the iliac veins and inferior vena cava. Br J Radiol 38:798–801PubMedGoogle Scholar
  44. 44.
    Mori H, Hayashi K, Amamoto Y (1986) Membranous obstruction of the inferior vena cava associated with intrahepatic portosystemic shunt. Cardiovasc Intervent Radiol 9:209–213PubMedGoogle Scholar
  45. 45.
    Sonin AH, Mazer MJ, Powers TA (1992) Obstruction of the inferior vena cava: A multiple-modality demonstration of causes, manifestations, and collateral pathways. Radiographics 12:309–322PubMedGoogle Scholar
  46. 46.
    Butler-Howe LM, Boothe HWJ, Boothe DM, G.A. L, Calvin JA (1993) Effects of vena cava banding in experimentally induced multiple portosystemic shunts in dogs. Am J Vet Res 54:1774–1783PubMedGoogle Scholar
  47. 47.
    Nakamura K, Takashima S, Kichikawa K, Uchida BT, Keller FS, Rosch J (1993) Portal decompression after transjugular intrahepatic portosystemic shunt creation with use of a spiral Z stent. J Vasc Interv Radiol 4:85–90PubMedGoogle Scholar
  48. 48.
    LaBerge JM, Ring EJ, Gordon RL, Lake JR, Doherty MM, Somberg KA, et al (1993) Creation of transjugular intrahepatic portosystemic shunts with the Wallstent endoprosthesis: Results in 100 patients. Radiology 187:413–420PubMedGoogle Scholar
  49. 49.
    Putnam JS, Uchida BT, Antonovic R, Rosch J (1988) Superior vena cava syndrome associated with massive thrombosis: Treatment with expandable wire stents. Radiology 167:727–728PubMedGoogle Scholar
  50. 50.
    Rosch J, Uchida BT, Hall LD, Antonovic R, Peterson BD, Ivancov K, et al (1992) Gianturco-Rosch expandable Z-stents in the treatment of superior vena cava syndrome. Cardiovasc Intervent Radiol 15:319–327PubMedGoogle Scholar
  51. 51.
    Gill E, Imaizumi T, Carveth H, Topham M, Tarbet E, McIntyre T, et al (1998) Bacterial lipopolysaccharide induces endothelial cells to synthesize a degranulating factor for neutrophils. FASEB J 12:673–684PubMedGoogle Scholar
  52. 52.
    Carde D, Xiao F, Moak C, Willis B, Robinson-Jackson S, Alexander S (1998) Neutrophil elastase promotes lung microvascular injury and proteolysis of endothelial cadherins. Am J Physiol 275:H385–H392Google Scholar
  53. 53.
    Yasuno M, Onodera T, Karata R, Ishida M, Saito Y, Takahashi M (1984) Pulmonary embolism as a complication of transfemoral arteriography. Jpn Circ J 48:439–445PubMedGoogle Scholar
  54. 54.
    Bataller R, Gines P, Arroyo V (1997) Practical recommendations for the treatment of ascites and its complications. Drugs 54:571–580PubMedCrossRefGoogle Scholar
  55. 55.
    Marre R, Schulz E, Hedtke D, Sack K (1985) Influence of fosfomycin and tobramycin on vancomycin-induced nephrotoxicity. Infection 13:190–192CrossRefPubMedGoogle Scholar
  56. 56.
    Saito H, Sakurai Y, Aoki T, Takamura A, Horio K, Morita Y (1994) Clinical application of expandable metallic stent for stenosis of the inferior vena cava caused by malignant tumor. Jpn J Clin Radiol 39:235–241Google Scholar
  57. 57.
    Wilhelm K, Schild H, Bruch E, Mildenberger P, Strunk H, Textor J, et al (1995) Stent implantation as a palliative therapeutic measure in tumor-induced stenoses of the large veins of the body. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 162:514–520PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2005

Authors and Affiliations

  • Kazushi Kishi
    • 1
    • 2
  • Tetsuo Sonomura
    • 3
  • Hisashi Fujimoto
    • 4
  • Masashi Kimura
    • 1
  • Katsuya Yamada
    • 1
  • Morio Sato
    • 1
  • Masanobu Juri
    • 5
  1. 1.Department of RadiologyWakayama Medical UniversityWakayama CityJapan
  2. 2.Department of RadiologySaiseikai Wakayama HospitalWakayama CityJapan
  3. 3.Department of RadiologyKishiwada Tokushukai HospitalKishiwada CityJapan
  4. 4.Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayama CityJapan
  5. 5.Department of SurgerySaiseikai Wakayama HospitalWakayama CityJapan

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