Case Series and Review of Literature for Superior Vena Cava Injury During Laser Lead Extraction.

Transvenous laser lead extraction poses a risk of major complications (0.19%-1.8%), notably injury to the superior vena cava (SVC) in 0.19% to 0.96% of cases. Various factors contribute to SVC injury, which can be categorized as patient-related (such as female gender, low body mass index, diabetes, renal problems, anemia, and reduced ejection fraction), device-related (including the number, dwell time, and type of leads), or procedural-related (such as reason for extraction, venous obstructions, and bilateral lead placements).

[Reconstruction of caval veins]. / Rekonstruktsiya polykh ven.

OBJECTIVE: To study the possibilities and results of reconstruction of caval veins. MATERIAL AND METHODS: We analyzed the results of reconstruction of caval veins in 31 patients (19 men and 12 women) including superior vena cava (SVC) in 5 cases and inferior vena cava (IVC) in 26 cases. Penetrating wounds with vascular damage were found in 8 patients. Iatrogenic damage to IVC was observed in 19 patients (nephrectomy for kidney cancer - 2, nephrectomy for secondary kidney wrinkling - 1, echinococcectomy from retroperitoneal space - 1, adrenalectomy for adrenal tumors - 5, right-sided lumbar sympathectomy - 1, resection of abdominal aortic aneurysm - 1, resection of a large retroperitoneal tumor - 6). Iatrogenic damage to SVC occurred in 2 patients during resection of mediastinal tumor. In other 4 cases, elective surgery for mediastinal tumor (1), pancreatic head cancer (2) and liver alveococcosis (1) was accompanied by resection and replacement of caval veins. RESULTS: All interventions for caval vein injury were performed under adequate infusion therapy. Seven (22.6%) patients died. One patient with blunt chest trauma and damage to SVC died during thoracotomy. In another patient, infrarenal IVC was intersected during mobilization of retroperitoneal hydatid cyst that required ligation for vital indications. High venous hypertension below the ligature led to eruption of sutures on the venous stump. The patient died from hypovolemia after additional IVC ligation. Other 5 patients died in early postoperative period without leaving the state of shock. These patients had damage to retrohepatic segment of IVC (1), vascular-organ (1) and iatrogenic (3) injuries. One patient died from pulmonary embolism, two patients - from venous bleeding between the 2nd and the 5th postoperative days. Patients died before reoperations. Two patients with postoperative bleeding underwent redo surgery with favorable outcomes. One patient underwent redo surgery for peritonitis with a favorable result. Thus, 7 (22.6%) patients with caval vein injury died in intraoperative and early postoperative period. Non-specific complications occurred in 4 (12.9%) patients. These events were corrected by conservative measures. Other 24 (77.4%) patients with traumatic and iatrogenic injuries of caval veins were discharged. CONCLUSION: Caval vein injury is less common event compared to other vascular damages. Nevertheless, this complication is accompanied by severe blood loss, shock and hypovolemia. We can only assume damage to a great vessel in patients with penetrating wounds before surgery and appropriate symptoms of internal bleeding. However, final diagnosis is made during surgery. Hemostasis is a responsible and difficult surgical stage in these patients. There is usually no alternative to reconstructive surgery in these cases. However, ligation is permissible in extremely ill patients and only in infrarenal segment of IVC. Vascular suture is a more acceptable and effective option for reconstruction. However, patch repair is advisable for large defects. In our opinion, this approach is better regarding long-term patency compared to total replacement with synthetic prostheses.

Successful avoidance of superior vena cava injury during transvenous lead extraction using a tandem femoral-superior approach.

BACKGROUND: Transvenous pacemaker and defibrillator lead extraction is a higher risk procedure with variation in preferred technique. A frequently fatal complication of this procedure is perforation of the superior vena cava. We have developed a tandem femoral-superior technique that incorporates snaring of targeted leads from a femoral approach combined with use of a rotational cutting sheath advanced over the lead from the subclavian vein. OBJECTIVE: We sought to evaluate the safety and efficacy of a tandem femoral-superior approach to lead extraction. METHODS: Consecutive patients undergoing transvenous extraction of at least 1 pacemaker or defibrillator lead with implant duration ≥1 year in which a tandem femoral-superior technique was used as the initial extraction strategy were included. The registry spanned 2010-2018 and consisted of procedures performed by a single primary operator. RESULTS: A total of 131 patients were included. A total of 267 leads with a mean implant duration of 9.8 years, including 90 defibrillator leads (33.7%), were targeted for extraction. No superior vena cava perforation or other vascular damage occurred. Clinical procedural success was achieved in 96.2% of cases. There were 5 major complications (3.8% of patients), with 3 being pericardial effusion requiring intervention. There were no deaths. CONCLUSION: A tandem femoral-superior approach to lead extraction effectively eliminated superior vena cava injury. This is a safe and effective technique for transvenous lead extraction.

Location of Superior Vena Cava Tears in Transvenous Lead Extraction.

BACKGROUND: Superior vena cava (SVC) tears are rare but potentially lethal complications associated with transvenous lead extraction. When lacerations occur, surgeons need to be prepared for an emergent response. Nonetheless, little is known about the precise whereabouts of these lesions. Understanding the location and injury patterns enables a more anticipated and targeted surgical response. METHODS: We collected data via physician interviews after an SVC laceration occurred. These physicians were identified through the US Food and Drug Administration's Manufacturer and User Facility Device Experience database and independent physician reports of adverse events. We identified 116 reports of SVC tears between July 1, 2016, and July 31, 2018. For an SVC tear to be included in our registry, a cardiothoracic surgeon had to be physically present to confirm the injury via emergent sternotomy. In each case, the surgeon recorded the SVC injury's exact location after a repair was attempted. RESULTS: During the study period, 116 SVC tears were confirmed by sternotomy. Tears occurred in any combination of the following locations: SVC-innominate vein, body of the SVC, and SVC-right atrial junction. The majority of tears (n = 72; 62%) were located in the isolated body of the SVC, followed by the SVC-right atrial junction (n = 23;19.8%) and the SVC-innominate junction (n = 17;14.6%). Combined tears were rare, accounting for only 3.6% (n = 4) of the adverse events recorded. CONCLUSIONS: Most SVC tears occurred in the isolated body of the SVC. The second most common location was the SVC-right atrial junction. The SVC-innominate junction was the third most common location for these injuries. Combined tears were uncommon.

Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction.

BACKGROUND: Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava-right atrium during transvenous lead extraction is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with transvenous lead extraction difficulty. METHODS: Serial imaging of leads occurred before transvenous lead extraction using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty was calculated for each patient and compared with IVUS findings. RESULTS: One hundred fifty-eight vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds, P<0.001) and median laser pulsations delivered (low=0 versus high grade=5852, P<0.001) were significantly higher in high-grade segments. Most patients with low lead extraction difficulty score had low ILA grades. Eighty-six percentage of patients with high lead extraction difficulty score had low IVUS grade, and the degree of transvenous lead extraction difficulty was similar to patients with low IVUS grades and lead extraction difficulty scores. CONCLUSIONS: IVUS is a feasible imaging modality that may be useful in characterizing ILA in the superior vena cava-right atrium region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging. Graphic Abstract: A graphic abstract is available for this article.

Abordaje toracoscópico de perforación iatrogénica de vena cava superior por catéter de diálisis / Thoracoscopic approach of iatrogenic superior vena cava perforation after dialysis catheter placement

No disponible

Prevention and treatment of dilator injuries during central venous catheter placement.

BACKROUND: Misuse of vascular dilators during the placement of central venous catheters has been infrequently reported and can lead to devastating intrathoracic hemorrhage and death. These injuries should be preventable in most cases. If a major intrathoracic vascular injury is recognized intraoperatively, less invasive treatment options are available to minimize the consequences. METHODS: The records of 20 patients who suffered 21 major vascular injuries during insertion of central venous catheters, ports, or dialysis catheters and resulted in malpractice claims over the course of 8 years were analyzed to determine the mechanism of injury, the timing of diagnosis, and how these injuries were treated. How the injury could have been prevented, why earlier diagnosis was not made, and what treatment options were possible were also examined. RESULTS: Twelve women and eight men were documented to have sustained intrathoracic major venous injuries during catheter insertions. There were five injuries to the superior vena cava, six to the right innominate vein, and 10 to the left innominate vein. All procedures were done using fluoroscopic guidance, and resistance to passage of the dilators was documented in eight cases. In most cases, the operator reported inserting the dilators to their maximum length. In four cases, the catheter could be seen intraoperatively in the thoracic cavity. Bleeding was diagnosed in the operating room in 11 cases, in the postanesthesia care unit in seven cases, and on postoperative days 2 and 5 after misplaced catheters were removed. Ten patients underwent thoracotomies and one patient each underwent thoracoscopy and placement of a covered stent in an attempt to stop the hemorrhage. Eight patients died before the diagnosis was made. Seventeen patients died. CONCLUSIONS: In spite of U.S. Food and Drug Administration warnings, dilators are still inserted too far in patients, resulting in devastating hemorrhage. These complications are preventable if proper technique is used. When a catheter is noted to be misplaced, it must not be removed before either a covered stent or thoracoscopy is available; otherwise, uncontrolled hemorrhage into the chest may occur. If a patient becomes unstable in the operating room or immediate postoperative period injury to a major vein must be considered and corrected quickly.

Endovascular Occlusion Balloon for Treatment of Superior Vena Cava Tears During Transvenous Lead Extraction: A Multiyear Analysis and an Update to Best Practice Protocol.

BACKGROUND: Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon. METHODS: We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration-maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality. RESULTS: From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used (P=0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04-0.40; P<0.001). CONCLUSIONS: From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.

[Difficulties in diagnosis of dislocated permanent dialysis catheter followed by perforation of right internal jugular and massive hemothorax]. / Trudnosti diagnostiki dislotsirovannogo permanentnogo dializnogo katetera, privedshei k massivnomu gemotoraksu pri perforatsii pravoi vnutrennei iaremnoi veny.

Great vein perforation followed by massive hemothorax occurred after implantation of permanent dialysis catheter. Diagnostic difficulties in this case were caused by placement of catheter's shadow in the projection of right atrium on the frontal X-ray scan. Injury of initial segment of superior vena cava was diagnosed during emergency surgery for ongoing bleeding.

Right Atrial, Right Ventricular, Superior Vena Cava Dissection Caused by Swan-Ganz Catheter Placement.

This case involves Swan-Ganz catheter placement in a patient who developed cardiogenic shock, possibly due to the catheter dissecting the intimal lining of the superior vena cava and endocardium.

Leiomiosarcoma de la vena cava superior con extensión a las cavidades cardíacas derechas / Leiomyosarcoma of the superior vena cava with extension to the right heart cavities

Fundamento: el leiomiosarcoma de la vena cava superior es una enfermedad rara y más cuando se extiende a las cavidades cardíacas. Objetivo: presentar una paciente con leiomiosarcoma de la vena cava superior que se extendió de forma intraluminal a las cavidades derechas del corazón lo que provocó obstrucción de las mismas y choque cardiogénico.Caso clínico: paciente de 45 años de edad, blanca, femenina sin antecedentes mórbidos de salud, la cual presentó enrojecimiento del rostro y agotamiento de las extremidades al peinarse. Se le realiza tomografía axial computarizada donde se identificó una lesión sugestiva de trombosis, se decide su traslado hacia un centro especializado, se llega a la conclusión de que la paciente era portadora de una lesión tumoral no trombótica, la cual resultó ser benigna en una biopsia realizada por lo cual se decide seguimiento. La paciente reingresa en estado de shock cardiogénico por progresión de la enfermedad y se decide su tratamiento quirúrgico de emergencia, durante la cirugía fallece. Conclusiones: el leiomiosarcoma de la vena cava superior es una enfermedad rara, existen pocos reportes en la literatura sobre este padecimiento. Se presentó un caso en el cual el tumor se extendía de forma intraluminal a las cavidades cardíacas derechas (aurícula y ventrículo)(AU)

Background: the leiomyosarcoma of the superior cava vein is a rare illness and more when it extends to the cardiac cavities. Objective: to present to the medical community a female patient with leiomyosarcoma of the superior cava vein that extended intraluminal form to the right cavities of the heart causing obstruction and cardiogenic shock. Clinical case: a 45-year-old white female patient with no morbid health history, who presented redness of the face and exhaustion of the extremities when combing. A computerized axial tomography was performed where a lesion suggestive of thrombosis was identified. It was decided to transfer her to a specialized center, in which it is concluded that the patient was a carrier of a non-thrombotic tumor lesion, which turned out to be benign in a biopsy done for which follow-up is decided. The patient reenters in a state of cardiogenic shock due to progression of the disease, which is why her emergency surgical treatment is decided and die during surgery.Conclusions: the leiomyosarcoma of the superior vena cava is a rare illness, with few reports in the literature. A case in which the tumor extended intraluminally to the right cardiac cavities (atrium and ventricle) is presented(AU)

Percutaneous endovascular treatment of an iatrogenic superior cava vein syndrome during the immediate post-operative period after mitral-aortic valve replacement. / Tratamiento endovascular percutáneo de un síndrome de vena cava superior en el postoperatorio inmediato de recambio valvular mitroaórtico.

Superior vena cava syndrome (SVCS) results from superior vena cava obstruction, causing a decrease in venous return from the head, neck, and upper extremities. Although the most frequent cause is still malignant tumour processes, in recent years an increase has been observed in non-tumour causes, such as thrombosis of intravascular devices or iatrogenic causes during cardiac surgery. A case is presented of SVCS after cardiac surgery treated satisfactorily by an endovascular technique and systemic anticoagulation.

Long-term follow-up of endovascular repair of iatrogenic superior vena cava injury: A case report.

RATIONALE: This report aimed to present the long-term follow-up results of the management of superior vena cava (SVC) rupture during balloon angioplasty in an attempt to relieve SVC obstruction as a result of hemodialysis (HD) catheter-related central vein stenosis. PATIENT CONCERNS: We present a case of a 42-year-old woman with end-stage renal disease on HD for 4 years, initially from an autogenous fistula for 2.5 years and then from a right internal jugular vein (IJV) catheter. She presented with clinical manifestations of SVC obstruction (dilated anterior chest wall and abdominal wall veins and facial swelling), which progressed over the last 1.5 years. DIAGNOSIS: A venogram confirmed right and left brachiocephalic vein and SVC obstruction. INTERVENTIONS: She underwent balloon angioplasty of the SVC through the right IJV, during which the dilated area ruptured, resulting in right hemothorax and hypovolemic shock. A covered stent was placed over the bleeding site, and the patient recovered. OUTCOMES: Rapid and skilled endovascular intervention through placement of a covered stent at the bleeding site can be lifesaving. LESSONS: It is superior to open surgical management in terms of complexity and morbidity especially in patients who are poor surgical candidates, and its durability is proving to be comparable.

Simultaneous lead traction from above and below: A novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction.

BACKGROUND: Superior vena cava (SVC) injury is a rare but dreaded complication during percutaneous transvenous lead extraction (TLE) that carries high morbidity and mortality. Despite technological advances and improved efficacy, complication rates remain unchanged. OBJECTIVE: We sought to develop and test a novel technique that could reduce the risk of SVC injury during TLE. METHODS: Fifteen patients referred for TLE of an implantable cardioverter-defibrillator lead were included. Patients underwent fluoroscopic and intracardiac echocardiographic (ICE) imaging of the lead-SVC interface with traction from above, below, and simultaneously. Clinical characteristics, fluoroscopic and ICE findings, and procedural outcomes were collected and analyzed. RESULTS: Fourteen of 15 patients were men (93%) with a mean age of 58 years. The mean lead dwell time was 8.09 ± 3.97 years (range 1.08-16.25 years), and 12 of 15 leads (80%) were dual-coil. Acceptable ICE imaging was not possible in 3 of 15 patients (20%). Simultaneous traction showed greater leftward fluoroscopic shift compared with traction from above (24.96 ± 8.82 mm vs 13.68 ± 6.86 mm; P < .01), created greater separation between the lead and the SVC wall upon ICE imaging (2.0 ± 0.52 mm vs 1.24 ± 0.38 mm; P < .01), and maintained a more parallel relationship of the lead with the SVC wall (24.41° ± 4.14° vs 27.91° ± 4.92°; P < .05). CONCLUSION: In patients presenting for TLE, simultaneous traction results in increased separation and a more parallel alignment of the lead and SVC wall, allowing the sheath to be better oriented in the desired cleavage plane. This improved sheath alignment is particularly critical when powered sheaths are to be used.

New-onset pericardial effusion during transvenous lead extraction: incidence, causative mechanisms, and associated factors.

PURPOSE: Pericardial effusion (PE) may occur during the lead extraction procedure (TLE). Little is known about the incidence, causes, and predictors of this complication. METHODS: From January 2009 to October 2016, TLE was attempted for 297 leads in 212 patients (age 69.3 ± 12.9 years, 169 male, BMI 27.2 ± 9.9 m²/kg, LVEF 43.4 ± 24.6%) for lead dysfunction (62.7%), upgrade (16.0%), infection (14.2%), or other (7.0%) indications. TLE was performed under general anesthesia with continuous invasive arterial blood pressure and transesophageal echocardiography (TEE) monitoring. For lead removal, the mechanical approach was first attempted, followed by the laser-assisted technique when needed. Severity of PE was defined by the presence of hemodynamically significant PE > 10 mm at TEE. RESULTS: Clinical success was achieved for 292 leads (98.3%). New-onset PE was observed in 14 patients (6.6%) [mild entity in 7 patients (3.3%) and severe in 7 (3.3%)]. In these latter patients, intra-procedural management included surgery (n = 3), pericardiocentesis (n = 2), or a conservative approach (n = 2). Right ventricular (RV) site lesions were treated with a simple fluid infusion. Laceration of the superior vena cava and other vessels resulted in rescue surgery. Lesions of the right atrial free wall (n = 1) and coronary sinus (n = 1) were treated with pericardiocentesis. NYHA III/IV, LVEF < 35%, renal impairment, right-sided implant, and ≥2 leads targeted for TLE were associated with new-onset PE. More than two factors identified a higher risk group (16.2%, 95% CI 6.2-32.0%, P = 0.02). CONCLUSIONS: New-onset PE is common during TLE and is associated with specific factors. PE severity and subsequent patient management depend on the site of injury.

A planned complex suicide by self-stabbing and vehicular crash: An original case and review of the literature.

Suicide is a frequent manner of unnatural death, especially from a forensic point of view. Complex suicide is defined as a recourse to more than one potentially lethal mechanism to deliberately induce death. This paper presents a complex suicide with a novel combination of self-killing methods. A 27 year-old man, working as a butcher, was found dead in his crashed car. The facts were initially in favour of an obvious traffic accident until a knife was discovered penetrating the driver's chest, requiring the police who were on the scene to carry out a criminal investigation. The cause of death was a major hemorrhagic process due to vascular thoracic lesions and internal blood loss. Based on the circumstances surrounding the death, the police investigations and the findings at the autopsy, the case was classified as a planned complex suicide. Through this original combination of two methods of suicide, this paper underlines the significance of a complete criminal investigation supported by a detailed crime scene inspection and autopsy examination.