European Heart Journal (2002) 23, 1465–1470
doi:10.1053/euhj.2002.3260, available online at http://www.idealibrary.com on
Treatment of superior vena cava obstruction
secondary to pacemaker wires with balloon
venoplasty and insertion of metallic stents
N. Teo1, T. Sabharwal1, E. Rowland2, P. Curry3 and A. Adam1
1
Department of Interventional Radiology, Guy’s and St Thomas’ Hospital, London, UK; 2Department of
Cardiology, St Georges Hospital, London, UK; 3Department of Cardiology, London Bridge Hospital, London, UK
Aims Pacemaker wires can result in stenosis of the superior
vena cava and other central veins. The aim of this study is
to demonstrate the safety and effectiveness of treating
stenoses of the superior vena cava (SVC) and central veins
with balloon venoplasty and metallic stent insertion in the
presence of cardiac pacemaker wires.
Methods and Results Three patients were referred to the
department after developing symptomatic SVC obstruction
following implantation of a cardiac pacemaker several
years earlier. They were examined with duplex ultrasound
and venography, which revealed significant stenoses of
the central veins. These patients subsequently underwent
endovascular treatment which involved balloon dilation
and stent insertion. The treatment was successful in all three
Introduction
Cardiac pacemakers are inserted to control symptomatic
bradycardia, such as that seen with heart block or sick
sinus rhythm. Although local complications, including
thrombosis and stenosis within the central venous system, occur in up to 30% of patients with pacemakers,
symptomatic superior vena cava obstruction is, fortunately, uncommon[1]. Several factors may increase the
occurrence of venous thrombosis related to a pacemaker. The presence of more than one lead has been
associated with a higher likelihood of superior vena cava
obstruction[2,3]. Retention of a severed lead or previous
lead infection have also been implicated as potential
etiologic factors[4]. Little information is available on the
effect of stent placement over pacemaker wires in the
superior vena cava, of which the largest series consists of
four patients[5–7]. We report our experience with treating
three patients with superior vena cava obstruction
Revision submitted 19 March 2002, and accepted 20 March 2002.
Correspondence: Dr Ngee Teo, Department of Radiology, St
Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK
0195-668X/02/$35.00
patients, without any complications. Long-term patency
of up to 4 years is recorded. No pacemaker function
dysfunction was encountered.
Conclusion SVC stenting is safe and effective in patients
who develop the SVC obstruction after cardiac pacemaker
insertion.
(Eur Heart J, 2002; 23: 1465–1470, doi:10.1053/euhj.2002.
3260)
2002 The European Society of Cardiology. Published by
Elsevier Science Ltd. All rights reserved.
Key Words: Cardiac pacemaker, superior vena cava
stenosis, balloon venoplasty, venous stenting.
caused by pacemaker wires. These patients were successfully treated with balloon venoplasty and stenting of the
superior vena cava.
Materials and Methods
Between February 1994 and August 2000, three patients
underwent endovascular treatment of the superior
vena cava to treat symptomatic obstruction related to
the presence of pacemakers. The data were collected
prospectively and are summarized in Table 1.
Two patients had intravenous heparin during the
procedure but no anticoagulants were used in one, who
had a bleeding diathesis of unknown cause.
Case 1
A 63-year-old woman presented with facial swelling
and engorged veins. Six years previously she had had
a dual chamber DDD (ICHD) (dual chambers, dual
mode of action; triggering and inhibition)[8] pacemaker
2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.
1466
N. Teo et al.
Table 1
Patient 1
Patient 2
Patient 3
Patient data
Presenting
age
Sex
Pacer
type
Route of
pacer insertion
Duration to
SVCO
63 years
78 years
35 years
F
F
F
DDD
AAI
DDD
(L) subclavian
(R) subclavian
(R) subclavian
5 years
3 years
4 years
for problems of sino-atrial and atrio-ventricular node
block. Pertinent past medical history included hypertension, a severe bleeding diathesis of unknown cause and
worsening atrial fibrillation. The propensity to bleed was
investigated extensively but no laboratory abnormalities
were found and its cause remains unknown.
Clinical examination was in keeping with superior
vena cava obstruction. A bilateral arm venogram confirmed SVC obstruction, with severe stenosis at the
origin of the superior vena cava and the left innominate
and right subclavian veins (Fig. 1(a)). There were
numerous collateral veins in the neck.
In view of her propensity to bleed, she was started on
tranexamic acid and aprotinin immediately before the
procedure on an empirical basis. Access was obtained
via the right groin. The stenosis in the SVC was dilated
with a 12 mm-diameter, 4 cm-long balloon (Ultra-thin
Diamond, Boston Scientific Inc, Natick, Mass., U.S.A.)
(Fig. 1(b)). The stenoses of the left brachiocephalic and
right subclavian veins were dilated with a 10 mmdiameter, 4 cm-long balloon (the right subclavian vein
was stenosed following previous pacemaker insertion
from the right side). Following venoplasty there was
re-establishment of flow within the superior vena cava
(Fig. 1(c)), and collaterals on the right side stopped
filling; small collaterals were still evident on the left
(Fig. 1(d)). As there was substantial improvement of
venous return from the head, neck and upper limbs
following the venoplasty we did not proceed to stent
placement.
The symptoms of superior vena cava obstruction
began to improve almost immediately and she continues
to be free 18 months after the procedure. There have
been no untoward effects on the function of the cardiac
pacemaker.
Case 2
A 78-year-old female retired physician had an AAI
(atrium chamber paced and sensed, response mode
inhibited)[8] pacemaker inserted via the right subclavian
vein 6 years ago, to treat sick sinus syndrome. Three
years later she developed superior vena cava obstruction, which manifested itself with facial edema and a
feeling of congestion in the head and neck. Computer
tomography showed stenoses of the superior vena cava
and the origin of the right subclavian vein, which was
confirmed on venogram (Figure 2(a)). Venoplasty with
12 mm balloons produced poor immediate result. Therefore, two Gianturco Z stents, each 30 mm in diameter
and 5 cm long (William Cook Europe A/S) were
inserted (Figure 2(b)), extending from the right innominate vein to the superior vena cava (Figure 2(c)). Her
symptoms improved markedly and there were no untoward effects on her cardiac pacing. Warfarin was
administered for 6 months after the procedure.
She continues to enjoy good health at 4 years after the
procedure and was especially pleased to be able to
resume her game of golf.
Case 3
A 35-year-old woman had previous radiofrequency
ablation for re-entry supra-ventricular tachycardia. A
dual chamber DDD[8] pacemaker was subsequently
inserted from the right subclavian route to treat the
arrhythmia.
Four years after insertion of the pacemaker she
developed significant clinical features of superior vena
cava obstruction, including facial swelling, and had an
uncomfortable sensation of ‘congestion’ in the head and
neck. Contrast-enhanced computer tomography of the
thoracic inlet confirmed superior vena cava obstruction
and shunting into small collateral veins in the neck.
Venography via a right femoral vein approach
demonstrated severe stenoses of the superior vena cava
and of the origins of both innominate veins. These were
dilated with 12 mm and 16 mm balloons but the tissues
immediately recoiled to their previous position. Therefore, two Gianturco Z stents (William Cook Europe
A/S), each 20 mm in diameter and 5 cm long, were
inserted, extending from the right internal jugular vein
into the superior vena cava.
Figure 1 (a) 63-year-old woman with DDD cardiac pacemaker inserted 6 years ago, now presenting with facial
swelling and upper limb venous congestion on exertion. The venogram shows severe stenosis of the proximal SVC and
left brachiocephalic vein. (b) Dilation of the narrowing with a 12 mm4 mm balloon. (c) Post venoplasty study shows
improvement of flow into the SVC, although there is a mild residual stenosis. (d) Post venoplasty study of left
brachiocephalic stenosis showing free flow across the previous obstruction and significant reduction in the collateral flow.
Eur Heart J, Vol. 23, issue 18, September 2002
Superior vena cava obstruction
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Eur Heart J, Vol. 23, issue 18, September 2002
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N. Teo et al.
Figure 2 (a) 78-year-old woman who developed symptomatic SVC obstruction after AAI cardiac pacemaker
was inserted 3 years earlier. This catheter directed venogram shows severe stenosis of the proximal SVC and
filling of multiple collaterals at the thoracic inlet. (b) Post stenting radiograph of the same patient shows a
Gianturco stent extending from the right internal jugular vein to the SVC. (c) Digital subtraction radiograph
shows free flow across the SVC stenosis that was stented. The collaterals are also conspicuous by their absence.
Within 2 days the facial swelling resolved. Warfarin
and aspirin were administered for 4 months after
the procedure. The patient remains free of symptoms
2 years after the procedure. The function of the cardiac
pacemaker has not been affected.
Eur Heart J, Vol. 23, issue 18, September 2002
Results
The procedure was technically successful in all cases,
with no subsequent stent migration, fracture, collapse or
occlusion. Testing of the pacemaker confirmed normal
Superior vena cava obstruction
function after stent placement in all patients. All patients
experienced rapid relief from the symptoms of superior
vena cava obstruction, and remained well with normal
pacemaker function at a mean follow-up of 30 months.
(range, 18–48 months) There were no complications
related to the procedure.
Discussion
Obstruction to the venous outflow from the head and
neck can result in severe morbidity. Patients can present
with facial congestion and swelling and engorged and
distended upper limb veins. With severe obstruction,
there can be difficulty in lying down and breathing,
disturbing sleep. These symptoms and signs are known
as the Superior Vena Cava Obstruction syndrome. This
is usually caused by malignant disease, such as bronchial
carcinoma or lymphoma, but can be related to mediastinal fibrosis caused by radiotherapy, tuberculosis, or
collagen vascular disease.
In these patients with superior vena cava obstruction
caused by malignant tumors, radiotherapy and/or
chemotherapy are the most common first-line methods
of treatment. However, recent publications have shown
that balloon venoplasty and stenting, which may be
augmented by catheter related thrombolysis, are useful
alternatives[9]. The results of stent insertion are excellent,
as there is high percentage of technical success and rapid
relief of symptoms. These techniques can be combined
with chemotherapy for the treatment of the malignant disease. Stenting is also indicated where there
are recurrent or unresolved symptoms after maximal
radiotherapy.
In contrast, treatment for benign causes of superior
vena cava obstruction is often protracted, punctuated by
multiple episodes of recurrences. These causes include
arterio-venous shunt or central lines placed for haemodialysis; or other iatrogenically introduced devices, such
as central lines, particularly those for long-term drug
therapy, or cardiac pacing wires. Infection along central
venous catheters and cardiac pacemaker leads is a
well-known predisposing factor. Venous angioplasty
and stenting in patients with arterio-venous shunts are
often repeated, with cumulative patency approaching
80% at 2 years[10,11].
In cases related to cardiac pacing wires, removal of
the device is not only often undesirable, in view of the
cardiac arrhythmia, it is also often impossible and may
not relieve the symptoms. The leads, which are insulated
by silicon, are covered by endothelium and become
incorporated into the vascular wall[12]. The pacing wires
can also become incorporated into the vascular walls
and heart chambers, making removal both difficult and
sometimes dangerous. Thrombosis can occur along
these wires leading to stenoses and occlusions of the
great veins[13]. Trauma to the vessel wall during insertion, infection and dual chamber systems are thought to
be predisposing factors[14].
1469
Data regarding treatment options are limited, in
view of the low incidence of superior vena cava
obstruction after insertion of a cardiac pacemaker.
Surgical treatment involves the insertion of a bypass
graft between the left innominate or jugular vein and
the right atrial appendage using an autologous or
Dacron graft[15,16]. This operation is performed only in
patients with benign disease, in whom the life expectancy is relatively long; it is a very invasive and difficult
option, which should be avoided if possible.
Reluctance to use venoplasty and stenting in these
patients with superior vena cava obstruction caused by
pacing wires is related to concerns that the balloon
might dislodge the wires, or that pressure by the metallic
stent on the wires may lead to malfunction of the
pacemaker. As it has been shown that the pacing leads
become incorporated to the venous wall, there is no
direct contact of the venoplasty balloon or stent with it.
This series has shown that in the short and medium
term, there is no disruption to the pacing wires, and that
venoplasty and stenting can be used safely in these
patients.
In the two patients stented in this article, we chose the
Gianturco Z stents over other types of endoprostheses
with a larger number of metallic struts, such as the
Wallstent, because it is generally believed that a smaller
number of stent struts in the Gianturco endoprostheses
reduces the risk of thrombosis[17].
Conclusion
Superior vena cava obstruction is a recognized, fortunately rare, complication pacemaker implantation. This
study and other small series, have shown that balloon
venoplasty and stenting can be safely performed in the
presence of pacemaker leads.
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