[HSF] Occluded SVC

[John Pym]

Hal

I agree with those who advise anticoagulation and waiting for the clot to
lyse (most likely) or for further venous collaterals to form. The important
point is that the patient does not have a full-blown SVC syndrome and is
therefore unlikely to deteriorate from this point of view - he already has
collaterals.

Another significant consideration is the fate of the pacing wires. What if
the leads become infected or the pacemaker erodes or the RV lead needs to be
extracted to provide venous access for an ICD lead (not uncommon in this day
and age)? You would be looking at a very unpleasant open redo if the
leads are locked in place by a stent.

John Pym

On Jan 31, 2008 7:11 AM, <Hgrmd at aol.com> wrote:

> Dear Members,
>  First, it was such a pleasure to meet several of you for the first  time
> at
> the HSF dinner.
>  I need some urgent advice.  About 2 weeks ago, I did a redo  AVR, mitral
> repair, tricuspid repair, Cox-maze on a 75 yo man.  Intraop,  while
> retracting
> the atrial septum for the work in the LA, noncircumferential  intimal
> tears
> developed on both the SVC and IVC.  I could tell because  there was
> substantial
> venous blood coming from underneath the SVC and IVC.   I was able to
> repair
> both with external suturing.  The rest of the case  went well.  About a
> week
> later, we inserted a DDD pacemaker (the patient  had been in continuous AF
> for
> years).  A few days later, he developed  severe facial and upper extremity
> swelling.  Workup reveals he has an  occluded SVC.  The cardiologist took
> him to the
> lab and measured a 30 mm  gradient across the SVC.  The patient is
> ambulating
> well and generally  feels OK, but he has the persistent swelling.  There
> is
> no evidence of  symptomatic intracranial swelling or upper airway
> compromise.
> The  cardiologist insists something must be done.  I'm reluctant to have a
> stent  deployed in a fresh heart.  The surgical option would be to extract
> the
> thrombus on CPB and patch the SVC.  My question is:  Is it  justified?
>
> Hal
>
>
>