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Management of superior vena caval obstruction secondary to a pacing wire with percutaneous intravascular stent insertion

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Superior vena caval (SVC) syndrome following permanent pacemaker implantation is an uncommon complication and may occur as a consequence of thrombosis, stenosis or both. Accepted modes of treatment include thrombolysis, surgery, and percutaneous transluminal coronary angioplasty (PTCA).

A 77 year old man presented 8 years after AAI pacemaker insertion with a six month history of progressive dyspnoea and facial oedema. On examination he had the classic findings of SVC obstruction. Contrast enhanced computed tomography confirmed an intravascular SVC filling defect enveloping the pacing wire extending from the left brachiocephalic vein to right atrium.

Tissue plasminogen activator administration (90 mg over 2 hours) followed by 48 hour heparin infusion failed to recanalise the vessel. Right heart catheterisation confirmed complete SVC occlusion with drainage via the azygous system (left). A 12 mm angioplasty balloon was successfully inflated at the right atrium/SVC junction but deflation resulted in immediate re-occlusion. A 16 × 56 mm self expanding Wallstent was inserted and dilated with a 20 mm valvotomy balloon. Subsequent angiography demonstrated free flow of contrast into the right atrium (right). Oral ticlopidine (250 mg bid) was given for two weeks and the patient was prescribed warfarin. Pacing checks before and after the procedure were unremarkable. At three months he remained asymptomatic.

Fear of pacing wire damage has resulted in underuse of stents in treating SVC syndrome with only one previous report of such a procedure. This report demonstrates that stents can be used safely in resistant cases.