Delayed Presentation of Totally Avulsed Right Superior

Vena Cava After Extraction of Permanent

Pacemaker Lead
MARZIA LEACCHE, YAN KATSNELSON, HASSAN ARSHAD, TOMISLAV MIHALJEVIC,
JAMES D. RAWN, MICHAEL O. SWEENEY, and JOHN G. BYRNE
LEACCHE, M., ET AL.: Delayed Presentation of Totally Avulsed Right Superior Vena Cava After Extraction
of Permanent Pacemaker Lead. Pacemaker lead extraction has been shown to be an effective and safe
treatment for infected permanent pacemaker leads, however, they may lead to potentially serious compli-
cations, usually occurring during the extraction procedure. This report describes a case of a 48-year-old
woman with a patent persistent left SVC and an infected permanent pacemaker lead of a DDD pacing
system who underwent transvenous laser-assisted lead extraction using a combined SVC and femoral
approach. Two days after the procedure the patient developed symptoms of SVC obstruction requiring
surgical intervention. The right SVC was found to be almost completely destroyed with only a thin strip of
the lateral wall intact and active bleeding. The probable causative mechanisms and surgical management
are discussed. (PACE 2004; 27:262263)
right superior vena cava avulsion
Introduction
Pacemaker lead extraction is the treatment of
choice for infected permanent pacemaker leads.
The probability of major complications during this
procedure is 0.63.3%,
1
and since the majority
are present during the extraction procedure they
can be treated immediately. This report describes
a patient with a persistent left superior vena cava
(SVC) in whom total avulsion of the right SVC
occurred during lead extraction with a delayed
presentation.
Case Report
A 48-year-old woman was admitted with an
infected permanent pacemaker lead of a DDD pac-
ing systemthat was placed for sinus node dysfunc-
tion when she was 28 years old. At the age of 7, the
patient underwent an atrial septal defect (ASD) re-
pair with pericardial patch via sternotomy. In ad-
dition, the patient had a patent persistent left SVC.
Transvenous, laser-assisted lead extraction was
undertaken using a combined SVCand femoral ap-
proach. The procedure was complicated by a mild
transient hypotension related to extraction of the
lead from the right SVC. A small nonexpanding
hematoma abutting the right SVCwas documented
on intraoperative transesophageal echocardiogra-
phy (TEE), but the patient remained stable and the
procedure was completed. The ventricular pacing
lead system was removed only partially, while the
Address for reprints: John G. Byrne, M.D., Brigham & Womens
Hospital, Div. of Cardiac Surgery, 75 Francis St., Boston MA
02115. Fax: (617) 732 6559; e-mail: jbyrne@partners.org
Received April 2, 2003, accepted April 24, 2003.
atrial leads were completely removed. A tempo-
rary transvenous pacemaker was installed.
On postoperative day 1 the patient developed
mild tachycardia. Symptoms of SVC obstruction
began as facial and right arm swelling. Chest com-
puted tomography (CT) revealed a hematoma mea-
suring 4.5 cm in diameter in the region of the right
SVC and a moderate right pleural effusion (Fig. 1).
Intravenous contrast failed to document extrava-
sations but also revealed a completely occluded
right SVC. Two days after permanent pacemaker
lead extraction, the patient demonstrated a 6-point
decrease in hematocrit and further signs of SVC
syndrome. Cardiac surgery was consulted and the
patient was brought to the operating room for con-
trol of bleeding, reconstruction of the right SVC,
and concomitant placement of epicardial pacing
leads. The previous median sternotomy was re-
opened on femoral cardiopulmonary bypass. Af-
ter partial removal of a well-formed thrombus, the
right SVC was found to be almost completely de-
stroyed with only a thin strip of the lateral wall
intact. The thrombus and small remaining part
of the permanent pacemaker lead were then re-
moved. There was no major backbleeding from
the avulsed subclavian and jugular veins, which
extended underneath the clavicle. At this point,
reconstruction of the right SVC was considered.
2
However, since the patient had signicant chronic
stenosis of the right SVC and a widely patent
left SVC, ligation of the right SVC was consid-
ered to be the best course of action. Therefore,
the right subclavian and jugular veins were lig-
ated. The right SVC and right atrium were over-
sewn using 4-0 prolene. The patient was weaned
from cardiopulmonary bypass. Permanent epicar-
dial ventricular and atrial pacing electrodes were
262 February 2004 PACE, Vol. 27
RIGHT SVC AVULSION
Figure 1. Contrast-enhanced computed tomography
scan showing the hematoma in the region of the right
superior vena cava (straight arrow) and the right pleu-
ral effusion (curved arrow).
appliedandconnectedto the newDDDpacemaker.
The patient was extubated on postoperative day
2, after her oropharyngeal swelling had decreased.
She was discharged a week later in good condition
with complete resolution of her SVC syndrome.
Discussion
After implantation of permanent pacemakers
0.57% of these become infected.
3
In the case of a
localized infection, local treatment of the pocket
and contralateral insertion of a new pacemaker
unit is the preferred treatment, while an infected
pacemaker lead requires its extraction. Internal
traction techniques using locking stylets and outer
sheets via the implant vein (the superior vein ap-
proach) to grab the pacemaker lead, or sheaths,
snares, and retrieval baskets via the femoral vein
have been reported to be able to extract a high pro-
portion of permanent pacemaker leads.
3
Recently, laser sheaths, using photoablation,
have been introduced to interrupt the scar tissue
binding the lead to the myocardium or veins and,
therefore, minimizing the risk of injury during per-
manent pacemaker lead extraction.
4
The SVC is a
thin low blood pressure vessel that can be injured
during stenting or venous catheter procedures. In-
jury is mostly limited to perforation or laceration.
Previously, a laceration of the SVC due to poly-
mer sheath advancement leading to the hemoth-
orax has been described, but its presentation was
immediate.
3
Smith et al.
5
described a delayed SVC
perforation after wallstent insertion for SVC ob-
struction related to mediastinal malignancy. The
delayed presentation, 6 months after the proce-
dure, was probably due the gradual erosion of the
SVC made fragile from chemotherapy and tumor
shrinkage of the SVCwall. The present report is the
only case of a SVC avulsion during a transvenous
pacemaker lead extraction with a delayed presen-
tation. In the present study the delayed presenta-
tion in the patient was due the presence of a left
SVC that is commonly associated with congenital
cardiac defects and with an ASD. Sinus node dys-
function may also be present with an ASD,
6
which
in this case led to pacemaker implantation for the
patient.
Normally, a persistent left SVC would be in-
signicant with regard to hemodynamics. How-
ever, inthis patient, because of the chronic stenosis
in her right SVC, likely related to the indwelling
permanent pacemaker leads, the left SVC was
widely patent, delaying the symptoms of SVC syn-
drome. Later a large hematoma developed leading
to the development of obstruction not only in the
right SVC, but also in the left SVC. Due to the pres-
ence of a widely patent left SVC, the presentation
of this complication was not immediate and did
not manifest until at least 1 day after the operation,
when the hematoma was large enough to obstruct
the left SVC.
After removal of the large thrombus, it was dis-
covered that the right SVC was mostly destroyed.
In a patient with normal anatomy, SVC reconstruc-
tion would have been appropriate, and this was
considered at rst. However, the presence of a left
SVC provided an alternative because of its wide
patency. Thus, after ligation of the remaining right
SVC, ligation of the jugular and subclavian veins
was performed. This allowed blood to be shunted
through the left SVC, which was widely patent af-
ter evacuating the hematoma, thus relieving the
SVC syndrome.
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