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Archives of cardiovascular diseases
Volume 106, n° 11
pages 624-626 (novembre 2013)
Doi : 10.1016/j.acvd.2012.01.013
Received : 23 November 2011 ;  accepted : 5 January 2012
Venous stenting as a treatment for pacemaker-induced superior vena cava syndrome
Mise en place d’un stent pour traiter un syndrome cave supérieur en relation avec un stimulateur cardiaque
 

Gabriel Laurent , Frédéric Ricolfi, Jean-Éric Wolf
CHU du Bocage, Dijon, France 

Corresponding author.

Keywords : Pacemaker, Superior vena cava syndrome, Venous stenting

Mots clés : Stent veineux, Stimulateur cardiaque, Syndrome cave supérieur

Abbreviation : SVC


An 86-year-old woman was referred to our institution for pacemaker dysfunction (right ventricular complete lead fracture; Figure 1). She had had double-chamber pacemakers (three device replacements) for complete atrioventricular block for 30years. A new ventricular lead was inserted via a right subclavian vein puncture. One year later, she started complaining about swollen eyelids and bloating of the head. The physical examination was normal except for gross distension of the neck veins. Contrast enhanced computed tomography confirmed partial intravascular obstruction of the superior vena cava (SVC) due to possible thrombosis. Anticoagulation therapy with 10days (heparin infusion followed by oral anticoagulants) failed to relieve the symptoms, which became progressively worse. General oedema of the upper body, increasing varicosities at the surface of the skin around the navel and large internal haemorrhoids were observed.



Figure 1


Figure 1. 

Chest X-ray with three leads in place: note that the old unipolar ventricular lead is completely severed.

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Superior venocavography showed proximal stenosis of the SVC with drainage via the azygous system (Figure 2, Figure 3). A self-expanding Wallstent® (Boston Scientific Corp., Natick, MA, US), 6cm in length, was inserted and deployed within the stenosis (Figure 4). The pacing electrodes were fixed between the wall of the SVC and the Wallstent® (Figure 5). Subsequent angiography showed free flow of contrast into the right atrium (Figure 6).



Figure 2


Figure 2. 

Superior venocavagram showed proximal stenosis.

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Figure 3


Figure 3. 

Digital subtraction angiogram of the superior vena cava showed its stenosis with drainage via the azygous system. Small arrows show central venous catheter; large arrows show contrast material through the azygous system.

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Figure 4


Figure 4. 

Insertion of a self-expanding Wallstent®, 6cm in length, deployed within the stenosis.

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Figure 5


Figure 5. 

Wallstent® in place (small arrows).

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Figure 6


Figure 6. 

Digital subtraction angiogram; once the stent was deployed, free flow of contrast was observed in the right chambers.

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Within 24hours of the procedure, congestion of the upper body had resolved. Warfarin was prescribed. At follow-up, 6weeks after the procedure, the previous symptoms and signs had resolved completely and the pacemaker was functioning normally.

SVC syndrome caused by stenosis around the leads (three in this case) is rare. This report demonstrates that stents can be used safely in severe cases of SVC syndrome. The Wallstent® is recommended to avoid electrode damage; however leads are trapped and cannot be removed in case of infection. This major limitation has to be taken into account.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.



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