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CASE REPORT
Endovascular Stenting of the Superior Vena
Cava-Right Atrial Junction in Combination With
Laser Lead Extraction for Iatrogenic Superior Vena
Cava Syndrome
Mitul P. Patel, MD; Brian Kolski, MD; Ehtisham Mahmud, MD
From the University of California Sulpizio Cardiovascular Center, San Diego, California.
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ABSTRACT: Iatrogenic superior vena cava (SVC) syndrome is a well described complication of pacemaker implantation leading to upper extremity swelling and symptoms of severe congestion from
elevation in venous pressures, especially with obstruction of the SVC at the right atrial junction. We
present a case of iatrogenic SVC syndrome that developed as a result of significant vascular fibrosis
at the superior vena cava-right atrial junction due to multiple pacemaker leads. In a unique therapeutic approach, after laser lead extraction, endovascular stenting of the SVC-right atrial junction
followed by lead replacement was performed using a hybrid surgical and endovascular approach.
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VASCULAR DISEASE MANAGEMENT 2014;11(6):E130-E135
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Key words: endovascular therapy, superior vena cava, stenting
atrogenic superior vena cava (SVC) syndrome is
a well described complication of pacemaker implantation.1 Patients with multiple transvenous
pacemaker leads can develop upper-extremity swelling and symptoms of severe congestion from elevation in venous pressures, due to obstruction of the
SVC and impaired emptying into the right atrium
(RA). Endovascular and surgical treatment of iatrogenic SVC syndrome has also been described with
multiple approaches to alleviate the obstruction into
the RA.2-4 We present a case of iatrogenic SVC syndrome that developed as a result of significant vascular fibrosis at the SVC-RA junction due to mul-
tiple pacemaker leads. Using a unique therapeutic
approach, after initial laser lead extraction, endovascular stenting of the SVC-RA junction and lead replacement using a hybrid surgical and endovascular
approach was performed.
CASE DESCRIPTION
A 47-year-old male presented with facial plethora
and upper-extremity swelling. He was known to be
pacemaker dependent for the previous 22 years due
to a high-grade atrioventricular conduction block
with original pacemaker leads placed in 1990 from
the left subclavian vein approach. However, due to
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CASE REPORT
tomography angiography revealed severe obstruction
at the SVC-RA junction (Figure 1).
TREATMENT
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Figure 1. Computed tomography demonstrating
multiple pacemaker leads resulting in stenosis at
the superior vena cava-right atrial junction.
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Due to nonfunctioning pacemaker leads and SVC
syndrome, definitive therapy was determined to include laser lead extraction in combination with possible
superior vena cava stenting and replacement of the patient’s dual chamber pacemaker leads. The procedure
was performed in a hybrid catheterization laboratory/
operating room with general anesthesia through both
right- and left-sided chest surgical incisions. Initially the
right sided atrial lead was extracted using a 12 Fr laser
sheath (Spectranetics), and the right-sided ventricular
lead with a 14 Fr laser sheath (Spectranetics) using multiple applications of laser energy (Figure 2).5 The same
technique was attempted to remove the left-sided leads,
but severe calcification and fibrosis were encountered
and ultimately overcome with a 13 Fr Evolution mechanical dilator (Cook Medical) with multiple alternating applications of mechanical dilations and rotations.
After lead extraction, intraoperative venography was
performed with digital subtraction and revealed severe
stenosis in the distal SVC at the right atrial junction
(Figure 3A). A resting mean gradient of 8mm Hg was
also measured between the SVC and RA.
A 55 cm 7 Fr sheath (Cook Medical) was then placed
in the right femoral vein, and a 45 cm 7 Fr sheath (Cook
Medical) was also placed in the left subclavian vein.
The subclavian sheath was used for balloon dilatation and stent delivery while the femoral sheath
was used for venography. Using a 0.035˝ 300 cm
Supra Core wire (Abbott Vascular) and under fluoroscopic and transesophegeal echocardiographic
Figure 2. Fluoroscopic image demonstrating 12
Fr and 14 Fr laser lead extraction sheaths advanced
over existing pacemaker leads.
lead failure in 2003, he required placement of 2 new
right-sided leads. As a result, he was known to have
2 nonfunctioning left subclavian leads and 2 functioning right subclavian pacemaker leads. Computed
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Figure 3. Digital subtraction angiography with simultaneous contrast injection in the superior vena cava
(SVC) and right atrium (RA) after laser lead extraction (A). Intraoperative transesophageal echocardiogram
demonstrating turbulent flow at the SVC-RA junction (B).
(TEE) guidance, sequential balloon inflations were
performed at the SVC-RA junction initially with a 5.0
mm x 40 mm EverCross balloon (Covidien), followed
by 8.0 mm x 40 mm and subsequently 10.0 mm x 40
mm EverCross balloons.
Ultimately, a 14.0 mm x 40 mm self-expanding Protege stent (Covidien) was positioned fluoroscopically
across the stenosis. The stent was positioned precisely
at the right atrial junction without protrusion into the
atrium as confirmed by TEE (Figure 3B). After optimal positioning, the stent was deployed and postdilated
with a 12.0 mm x 20 mm FoxCross balloon (Abbott
Vascular) (Figure 4). Final angiography and echocar-
diography (Figure 5) revealed excellent stent expansion with complete resolution of the resting pressure
gradient. Intra-procedural hemodynamics revealed a
decrease in central venous pressure from 14 mm Hg to 6
mm Hg following stent deployment and postdilatation.
Subsequently, new pacing leads were placed using the
right subclavian approach. At 4 months’ follow-up, the
patient was asymptomatic with complete resolution of
the SVC syndrome.
DISCUSSION
In this unique report we show that endovascular stenting at the SVC-RA junction can be performed with
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clinicians working together.
One of the major challenges in this procedure was
optimal visualization of the right atrium and SVC
junction. In addition, after extraction of all the leads,
there were multiple web-like channels composed of
scar tissue and organized thrombus further obstructing
the transition from the SVC to the RA and posing the
additional challenge of identifying the proper lumen
for stent deployment.
Simultaneous digital subtraction angiography via
catheters positioned in the caudal and cephalad positions and intraoperative TEE allowed for optimal
identification of the SVC-RA junction. Hemodynamic evaluation to measure pressure gradients from
the SVC to the RA across the obstruction was performed with separate pressure transducers from the
cephalad and caudal sheaths. Finally, the site of obstruction and maximal gradient were also identified
by a high-velocity transesophageal echocardiography
Doppler flow signal. Diminution of this gradient was
seen after sequential balloon dilations.
While the multidisciplinary approach to the management of SVC syndrome has been previously described,6,7 the use of intraoperative transesophageal
echocardiography and stenting of the SVC-RA junction are unique aspects of this case. Transesophageal
echocardiography during laser lead extraction improves the safety of a procedure known to have a 1%
to 2% risk of pericardial tamponade.8,9
In addition to assuring safety, the use of TEE was
instrumental in optimal positioning and deployment
of the self-expanding stent at the SVC-RA junction,
preventing extension into the right atrium. Significant extension of the stent into the right atrium could
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Figure 4. Postdilation with a 12 mm x 20
mm FoxCross balloon (Abbott Vascular) after
deployment of a 14 mm x 40 mm self-expanding
Protegé stent (Covidien).
current multimodality imaging. With the increased
implantation of pacemaker and defibrillator leads, iatrogenic SVC syndrome is a rare but clinically relevant
complication without a straightforward treatment. Although laser and mechanical lead extraction can be
effectively used to remove multiple leads causing the
mechanical obstruction in the SVC, subsequent treatment options are limited when the fibrosis extends from
the SVC into the right atrium. This report highlights
an endovascular therapy that was possible with a multidisciplinary approach using the “heart team” concept
in a hybrid catheterization laboratory and operating
room with interventional cardiology, electrophysiology, cardiothoracic anesthesiology, and cardiac surgery
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Figure 5. Final digital subtraction angiography after superior vena cava (SVC) stenting of the SVCRA junction (A). Final intraoperative transesophageal echocardiogram in the bicaval view displaying the
SVC-RA junction (red arrow) (B).
prevent stent endothelialization and predispose to potential thrombus formation and distal embolization
into the pulmonary vascular bed. Likewise, the hybrid
catheterization lab and operating room added an element of safety for a procedure known to have bleeding rates requiring thoracotomy up to 2.6%9-12 while
also allowing the versatility of high-quality imaging for
optimal endovascular intervention.
The concept of the “heart team” has recently been
highlighted in relation to treating patients with critical
aortic stenosis with transcatheter aortic valve replacement (TAVR). Interventional cardiologists, vascular
surgeons, and cardiothoracic surgeons work using a
team approach to devise a treatment and procedure
plan. Similarly, hybrid coronary and peripheral revascularization procedures are performed when heart and
vascular teams work to optimize patient outcomes.13,14
This report demonstrates an example of the “heart
team” approach in that endovascular SVC stenting
after multiple laser and mechanical lead extractions
followed by permanent pacemaker implantation was
only possible through this approach. With this multidisciplinary approach between cardiovascular medicine and surgery in a hybrid catheterization laboratory
and operating room, an optimal patient outcome was
achieved.
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Editor’s Note: Disclosure: The authors have completed
and returned the ICMJE Form for Disclosure of Potential
Conflicts of Interest. The authors report no conflicts of interest
regarding the content herein.
Manuscript received June 1, 2013; provisional acceptance
given July 29, 2013; final version accepted January 15, 2014.
Address for correspondence: Ehtisham Mahmud, MD,
Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, 9434 Medical Center Drive, La Jolla, CA 92037,
United States. Email: [email protected].
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In this case of iatrogenic SVC syndrome, which
developed as a result of vascular fibrosis at the superior vena cava-right atrial junction, a multidisciplinary “heart team” successfully treated the patient
using a hybrid surgical and endovascular approach.
After laser lead extraction, endovascular stenting of
the SVC-right atrial junction was performed using
angiography and transesophageal echocardiography
for optimal imaging followed by lead replacement. n
vein-right atrial bypass for relief of superior vena cava
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akir I, La Meir M, Degrieck I, Marien C,Van den Hauwe K, Wellens F. Contralateral replacement of pacemaker
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CONCLUSION
Acknowledgements: The authors would like to thank
Drs. Ulrika Green and Victor Pretorius for their contributions
to this manuscript.
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