Author + information
- Received September 7, 2016
- Revision received October 1, 2016
- Accepted October 6, 2016
- Published online May 15, 2017.
- aHeart Rhythm Centre, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
- bDepartment of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
- ↵∗Address for correspondence:
Dr. Tom Wong, Heart Rhythm Centre, The Royal Brompton & Harefield Hospitals, Sydney Street, London SW3 6NP, United Kingdom.
A 50-year-old man with a right-sided pectoral dual chamber defibrillator for cardiac sarcoid and complete heart block developed debilitating superior vena cava (SVC) obstructive symptoms, including facial swelling, arm swelling, headache, and distorted vision despite therapeutic anticoagulation. He previously had defibrillator system extraction for device infection on the left side. Contrast venography confirmed the presence of complex thrombi with complete occlusion of the right innominate vein in addition to subtotal occlusion of the left innominate vein and the high SVC junction (Figure 1A). Laser extraction of the defibrillator leads was performed via the right subclavian approach to relieve the obstruction on the SVC–right innominate vein junction. Via a femoral approach, the stenosed SVC–left innominate vein junction was pre-dilated using a 16 × 4-mm balloon over a guidewire positioned in a distal collateral branch of the left subclavian vein. A 48-mm stent mounted over a 16-mm balloon was delivered and deployed at the SVC–left innominate stenosis (Figure 1B). The laser sheath was then left adjacent to the sidewall of the stent to guide a wire through the stent strut (Figure 1C). A 10 × 40-mm balloon opened the strut, making space (Figure 1D) for the delivery of a right ventricular defibrillator lead and then an atrial lead. A high-pressure 16 × 4-mm balloon post-dilated the stent to optimize stent deployment (Figures 1E and 1F). Stent strut dilation is an adopted interventional treatment strategy for coronary bifurcation lesions to preserve side branch flow. We have demonstrated for the first time that percutaneous SVC–innominate vein stenting with defibrillator lead implantation via stent struts is a feasible strategy where the stent end lumen is not accessible. The placement of SVC stents adjacent to the pacing leads seems to be safe in the short term; however, the long term effects on lead integrity remain a concern. The integrities of the leads were intact at the 18-month follow-up and the patient did not exhibit any symptoms of SVC obstruction.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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- Received September 7, 2016.
- Revision received October 1, 2016.
- Accepted October 6, 2016.
- 2017 American College of Cardiology Foundation