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Ann Thorac Surg 2006;82:e41-e42
© 2006 The Society of Thoracic Surgeons

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Case Reports

Severe Superior Vena Cava Syndrome after Transvenous Pacemaker Implantation

^a Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
^b Department of Radiology, German Heart Center Munich, Technical University of Munich, Munich, Germany

Accepted for publication August 14, 2006.

^_* Address correspondence to Dr Wildhirt, Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, Lazarettstrasse 36, Munich, 80636 Germany (Email: wildhirt{at}gmx.net).

	Abstract

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Superior vena cava syndrome is a rare complication after pacemaker implantation. The present report outlines how underestimation of clinically relevant symptoms of superior vena cava syndrome early after pacemaker implantation may result in severe complication with the need for major surgical intervention. Superior vena cava syndrome should be diagnosed early because immediate thrombolytic therapy is effective in the majority of patients and avoids the requirement for interventional or surgical efforts.

	Introduction

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Venous complications after pacemaker implantation are usually asymptomatic. Superior vena cava (SVC) syndrome is a rare complication after pacemaker implantation. The present report outlines how underestimation of clinically relevant symptoms of SVC syndrome early after pacemaker implantation may result in severe complications with the need for major surgical intervention.

A 54-year-old woman underwent transvenous pacemaker implantation through the right subclavian vein for symptomatic sinus bradycardia at another institution in March 2003.

In November 2005, 34 months after the initial implantation, she presented at our hospital with progressive SVC syndrome, including the swelling of face, neck, and arm with emphasis on the right side of the body. Furthermore she complained about progressive dizziness and headache on exertion. The first symptoms had occurred as early as 1 week after pacemaker implantation. To our surprise, as early as 9 months after pacemaker implantation, in December 2003, right subclavian vein and right brachiocephalic vein thrombosis, as well as SVC stenosis had already been diagnosed. At that time she was put on Phenprocoumon (Marcumar, Hofmann–La Roche, Basel, Switzerland), but thrombosis persisted, symptoms aggravated, and she decided to report to our center for medical and surgical advice.

Venography revealed occlusion of the right brachiocephalic vein, patent innominate vein, severe SVC stenosis with retrograde filling of the azygos vein, and severe stenosis of the SVC distal to the azygos vein confluence (Figs 1A, 1B) reducing its diameter to 10 mm. Collateral veins providing adequate venous drainage could not be demonstated (Fig 1B). The decision for surgery was made.

View larger version (99K): [in this window] [in a new window]   Fig 1. Right and left arm venography showing right brachiocephalic vein thrombosis and severe superior vena cava (SVC) stenosis (white arrow, A, B), patent innonnimate vein (white star), pacemaker wires (black arrows) inserted in right subclavian vein, venous collaterals partially draining in azygos vein (A). (C) A 14-mm Gore-Tex prosthesis (W.L. Gore & Assoc, Flagstaff, AZ) anastomosed to innominate vein (white star) and right atrial appendage (white X). The SVC draining in right atrium is covered by the prosthesis. (D) Left arm venography on postoperative day 5 showing excellent venous drainage through the 14-mm Gore-Tex prosthesis (W.L. Gore & Assoc). Black arrows indicate proximal and distal anastomoses. Regular wash-out phenomenon within the prosthesis from jugular vein blood.

The innominate vein was dissected at its confluence with the right brachiocephalic vein and anastomosed in an end-to-end fashion with a 14-mm Gore-Tex prosthesis (W.L. Gore & Assoc, Flagstaff, AZ). The latter was anastomosed end-to-site onto the right atrial appendage (Fig 1C). Thereafter, no pressure gradient was detected between the innominate vein and the right atrium.

The patient’s symptoms improved dramatically. Swelling of the face, neck, and arms disappeared. A subsequent left arm venography on the fifth postoperative day demonstrated unimpaired venous drainage through the graft (Fig 1D).

The patient was discharged on the ninth postoperative day on Phenprocoumon (Hofmann–La Roche) with a target international normalized ratio of 2.5 to 3.0.

	Comment

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Fortunately symptomatic SVC syndrome after pacemaker implantation is rare. Goudevenos and colleagues [1] found 1 of 3,100, Chamorro and colleagues [2] found 4 of 1,000, Bolad and colleagues [3] found 3 of 3,050 patients suffering from SVC syndrome after transvenous pacemaker implantation.

However, the present report outlines how underestimation of clinically relevant symptoms of SVC syndrome early after pacemaker implantation may result in severe complication with the need for major surgical intervention.

At time of diagnosis, 9 months after pacemaker implantation, medical treatment failed. In addition, progression of appositional thrombus growth led to almost complete SVC occlusion, which made interventional therapy impossible in this patient.

Treatment of SVC syndrome includes medical therapy, interventional strategies, and surgical strategies.

With regard to early treatment of SVC syndrome, the success rate of early thrombolytic therapy is acceptable. In this regard, Gray and colleagues [4] reported that thrombolytic therapy in 16 patients with central venous catheter-related SVC obstruction had an 88% success rate if symptoms had been present for less than 5 days before treatment, but only a 25% success rate, if symptoms had been present for more than 5 days.

However in selected cases removal of the pacemaker with additional thrombolytic therapy or stenting may be indicated. In this case a transthoracic pacemaker should be placed intermittently.

Smayra and colleagues [5] reported on 30 patients receiving stent placement for vena cava syndrome. In 5 patients SVC stenosis was not related to malignancies. Secondary patency rate was 75% at 15 months follow-up with a 43% reintervention rate for re-stenosis or stent occlusion in all 30 patients.

Surgical treatment strategies of SVC syndrome include thrombectomy, polytetrafluoroethylene graft, and autologous spiral saphenous vein bypass grafting as described by Doty and colleagues [6]. Using the latter technique, the saphenous vein is harvested and incised longitudinally through its entire length. The opened vein is wrapped around a chest tube of the same diameter as the innominate vein with the endothelial surface covering the tube. A continuous suture joins the edges of the graft forming a conduit of appropriate diameter. After removal of the tube the conduit is anastomosed to the innominate vein and the right atrial appendage bypassing the obstructed SVC [6].

Acceptable long-term patency rates are reported for surgical therapy of SVC stenosis. Doty and colleagues [6] reported patency rates of 87.5% at 10.9 years and 80% at 5 years after SVC bypass grafting. Secondary interventional treatment for re-stenosis contributed to the patency rates reported in the studies of Doty and colleagues [6], Kalra and colleagues [7], and Alimi and colleagues [8].

The case reported here illustrates the course of delayed diagnosis of SVC syndrome after transvenous pacemaker implantation.

Therefore the early careful observation (within the first 1 to 2 weeks after implantation) of patients is necessary. If SVC syndrome is diagnosed, the immediate thrombolytic therapy is effective in the majority of patients and avoids the requirement for interventional or surgical efforts for SVC syndrome after transvenous pacemaker implantation.

	Footnotes

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^_* Both authors contributed equally to the article.

	References

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1. Goudevenos JA, Reid PG, Adams PC, Holden MP, Williams DO. Pacemaker-induced superior vena cava syndrome: report of four cases and review of the literature Pacing Clin Electrophysiol 1989;12:1890-1895.[Medline]
2. Chamorro H, Rao G, Wholey MH. Superior vena cava syndrome: a complication of transvenous pacemaker implantation Radiology 1978;126:377-378.[Abstract]
3. Bolad I, Karanam S, Mathew D, John R, Piemonte T, Martin D. Percutaneous treatment of superior vena cava obstruction following transvenous device implantation Catheter Cardiovasc Interv 2005;65:54-59.[Medline]
4. Gray BH, Olin JW, Graor RA, Young JR, Bartholomew JR, Ruschhaupt WF. Safety and efficacy of thrombolytic therapy for superior vena cava syndrome Chest 1991;99:54-59.
5. Smayra T, Otal P, Chabbert V, Chemla P, Romero M, Joffre F, Rousseau H. Long-term results of endovascular stent placement in the superior caval venous system Cardiovasc Intervent Radiol 2001;24:388-394.[Medline]
6. Doty JR, Flores JH, Doty DB. Superior vena cava obstruction: bypass using spiral vein graft Ann Thorac Surg 1999;67:1111-1116.[Abstract/Free Full Text]
7. Kalra M, Gloviczki P, Andrews JC, et al. Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease J Vasc Surg 2003;38:215-223.[Medline]
8. Alimi YS, Gloviczki P, Vrtiska TJ, et al. Reconstruction of the superior vena cava: benefits of postoperative surveillance and secondary endovascular interventions J Vasc Surg 1998;27:287-299300–1.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stephen M. Wildhirt Robert Bauernschmitt Ruediger Lange Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ruge, H. Articles by Lange, R. Search for Related Content PubMed PubMed Citation Articles by Ruge, H. Articles by Lange, R. Related Collections Electrophysiology - arrhythmias