Endovascular repair of an iatrogenic superior vena caval injury: A case report Ali Azizzadeh, MD, Mai T. Pham, MD, Anthony L. Estrera, MD, Sheila M. Coogan, MD, and Hazim J. Safi, MD, Houston, Tex We present the case of a patient with an iatrogenic injury to the superior vena cava during a central venous catheter placement. The vena cava was perforated when a left subclavian dialysis catheter was placed. The perforation in the right side of the vena cava occurred at the confluence of the innominate veins. This perforation was successfully repaired using a 10 mm Viabahn stent graft (W. L. Gore, Flagstaff, Ariz) delivered through a femoral approach. The stent graft was deployed as the dialysis catheter was removed. This case demonstrates the utility of stent graft repair of the superior vena cava in emergency situations. ( J Vasc Surg 2007;46:569-71.)
Iatrogenic venous injuries can occur during placement of central venous catheters. Among these, perforation of the superior vena cava may result in massive hemorrhage and hemodynamic instability. We present the case of a patient who developed a right hemothorax after a central venous catheter placement. Vascular surgery consultation was requested for management of the superior venal caval injury. This injury was successfully repaired using a stent graft. The patient recovered uneventfully. CASE REPORT The patient is a 54-year-old woman with a history of hepatitis C and hemachromatosis who underwent orthotopic liver transplantation in 1998. She was recently readmitted to the hospital for hepatorenal failure. The patient underwent a left subclavian vein tunneled hemodialysis catheter placement by her primary team. The surgeon did not report experiencing any difficulty during insertion of the dialysis catheter. Postoperative chest x-ray obtained in the recovery room demonstrated total opacification of the right chest and perforation of the superior vena cava by the catheter (Fig 1). Vascular surgery consultation was requested for management of the superior venal caval injury. The patient became hemodynamically unstable in the recovery room requiring multiple blood transfusions. She was emergently taken to the endovascular suite. A right tube thoracostomy was performed. Approximately 1 liter of blood was evacuated. Next, right common femoral venous access was obtained. A diagnostic venogram was performed. Extravasation of contrast was noted at the confluence of the innominate veins (Fig 2). The superior vena cava measured 8 mm in diameter at the level of the injury. The decision was made to proceed with an endovascular repair. The right groin sheath was exchanged for an 11F sheath. A 10 mm x 50 mm Viabahn stent graft (W. L. Gore, Flagstaff, Ariz) was positioned at the level of the injury. The stent graft was deployed as the hemodialysis catheter From the Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Heart and Vascular Institute. Competition of interest: none. Reprint requests: Ali Azizzadeh, MD, Assistant Professor, 6410 Fannin, Suite 450, Houston, TX 77030 (e-mail:
[email protected]) 0741-5214/$32.00 Copyright © 2007 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2007.04.014
was removed simultaneously. Post deployment angioplasty was performed using a 10 mm x 4 cm balloon. Completion venogram showed successful exclusion of the injury (Fig 3). The patient recovered uneventfully. She had no facial or upper extremity swelling. A follow-up bilateral upper extremity venous Doppler performed 3 weeks postoperatively did not show any evidence of deep venous thrombosis.
DISCUSSION Injury to the superior vena cava can be associated with hemodynamic instability, hemothorax, and pericardial tamponade. This is a potentially fatal complication if not recognized and treated promptly. Open repair requires a median sternotomy. Balloon angioplasty and stent placement has been described for treatment of various disease processes that give rise to superior vena cava syndrome.1,2 To our knowledge, nine cases of iatrogenic superior vena caval perforation have been reported in the literature.3-11 Three of these perforations have been directly related to balloon inflation.3-5 In one case, the perforation occurred during passage of a guidewire through an occlusion.6 Another perforation was reported during placement of a temporary pacemaker after the stent was placed.7 The remaining four perforations occurred up to 6 months after the original procedure.8-11 Four of the nine (44%) reported patients died secondary to the perforation. Two patients (22%) required median sternotomy for open repair, two patients (22%) underwent pericardial drain placement, and one patient (12%) had a stent graft repair. Burket reported the first successful stent graft repair of a superior vena caval rupture in 2003.3 This injury occurred after angioplasty for treatment of superior vena cava syndrome. The patient reportedly became “apneic and pulseless” after balloon inflation. A venogram was then performed to diagnose the injury. This was then repaired using a 10 mm by 50 mm Wallgraft (Boston Scientific Corporation, Natick, Mass). Endovascular repair has also been used for emergency repair of the inferior vena cava.12-14 In one case, a juxtahepatic inferior vena cava injury was repaired using a fenestrated stent graft while preserving hepatic venous return.14 Another case involved repair of uncontrollable hemorrhage that occurred during resection of a 569
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Fig 1. Postoperative chest x-ray demonstrating total opacification of the right chest and perforation of the superior vena cava by the catheter.
Fig 3. Completion venogram showing successful exclusion of the injury using a stent graft.
Fig 2. Diagnostic venogram showing extravasation of contrast from the superior vena cava.
retroperitoneal leiomyosarcoma.13 The most recent report involved stent graft repair of the inferior vena cava secondary to trauma.12 To our knowledge, this is the second reported case of an emergency stent graft repair of an iatrogenic superior vena caval injury. In contrast to the previously reported case, this injury occurred during placement of a dialysis catheter. Our patient was a poor candidate for open surgery due to acute hepatorenal failure. Endovascular repair permitted rapid sealing of the perforation with minimal morbidity. In surgically unfit patients or those with hemodynamic instability, endovascular intervention provides a viable option. Performing this procedure in an endovascular operating room allows for rapid conversion to open repair should that become necessary. A few technical points deserve mention. An expeditiously performed venogram can help identify the exact
location of the injury and guide the selection of a properly sized device. In this case, the superior vena cava measured 8 mm in diameter at the level of the injury. A 10 mm x 50 mm stent graft was selected to allow for slight oversizing. Interestingly, the same size stent graft was also used by Burket.3 A smaller length device was not available for use during this case. The injury could have been potentially sealed with a 25 mm length graft. Placing a longer length graft at the confluence of the innominate veins carries the risk of occlusion of one of the two branches. This could potentially lead to thrombosis of the upper extremity veins. We closely monitored the patient postoperatively for upper extremity swelling. Fortunately, she remained asymptomatic. A follow-up bilateral upper extremity venous Doppler performed 3 weeks postoperatively did not show any evidence of deep venous thrombosis. This case demonstrates the utility of stent graft repair for management of iatrogenic superior vena caval injuries. This technique affords control of often exsanguinating hemorrhage in a very rapid fashion. It is especially valuable in patients who are poor surgical candidates. However, the long-term patency of stent grafts in the venous system remains to be determined. Follow-up surveillance studies would be useful to monitor the patency of these implants. REFERENCES 1. Dondelinger RF, Goffette P, Kurdzeil J, Roche A. Expandable metal stents for stenosis of the vena cava and large veins. Semin Intervent Radiol 1991;8:252-63.
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2. Smayra T, Otal P, Chabbert V, Chemla P, Romero M, Joffre F, et al. Long-term results of endovascular stent placement in the superior caval venous system. Cardiovasc Intervent Radiol 2001;24:388-94. 3. Burket, MW. Challenging cases: superior vena cava rupture. Endovasc Today 2003;2:11-3. 4. Brown KT, Gertrajdman GI. Balloon dilation of the superior vena cava (SVC) resulting in SVC rupture and pericardial tamponade: a case report and brief review. Cardiovasc Intervent Radiol 2005;28:372-6. 5. Oshima K, Takahashi T, Ishikawa S, Nagashima T, Hirai K, Morishita Y. Superior vena cava rupture caused during balloon dilation for treatment of SVC syndrome due to repetitive catheter ablation--a case report. Angiology 2006;57:247-9. 6. Boardman, P, Ettles, DF. Cardiac tamponade: a rare complication of attempted stenting in malignant superior vena cava obstruction. Clin Radiol 2000;55:645-7. 7. Kee ST, Kinoshita L, Razavi MK, Nyman UR, Semba CP, Dake MD. Superior vena cava syndrome: treatment with catheter-directed thrombolysis and endovascular stent placement. Radiology 1998;206:187-93. 8. Brant J, Peebles C, Kalra P, Odurny A. Hemopericardium after superior vena cava stenting for malignant SVC obstruction: the importance of contrast-enhanced CT in the assessment of postprocedural collapse. Cardiovasc Intervent Radiol 2001;24:353-5.
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9. Martin, M, Baumgarter, I, Kolb, M. Fatal pericardial tamponade after Wallstent implantation for malignant superior vena cava syndrome. J Endovasc Ther 2002;9:680-4. 10. Recto, MR, Bousamra, M, Yeh, T, Jr.Late superior vena cava perforation and aortic laceration after stenting to treat superior vena cava syndrome secondary to fibrosing mediastinitis. J Invasive Cardiol 2002; 14:624-9. 11. Smith SL, Manhire AR, Clark DM. Delayed spontaneous superior vena cava perforation associated with a SVC stent. Cardiovasc Intervent Radiol 2001; 24:286-7. 12. Castelli P, Caronno R, Piffaretti G, Tozzi M. Emergency endovascular repair for traumatic injury of the inferior vena cava. Eur J Cardiothorac Surg 2005; 28:906-8. 13. Erzurum VZ, Shoup M, Borge M, Kalman PG, Rodriguez H, Silver GM. Inferior vena cava endograft to control surgically inaccessible hemorrhage. J Vasc Surg 2003;38:1437-9. 14. Watarida S, Nishi T, Furukawa A, Shiraishi S, Kitano H, Matsubayashi K, et al. Fenestrated stent-graft for traumatic juxtahepatic inferior vena cava injury. J Endovasc Ther 2002; 9:134-7.
Submitted Feb 20, 2007; accepted Apr 3, 2007.
