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Superior vena cava tear during transvenous lead extraction: Medical management in hemodynamically stable patients
Guillaume Domain1, Camille Strubé1, Frédéric Jacques2
1Electrophysiology Division, Institut Uuniversitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada.
Insights
Superior vena cava (SVC) tears during transvenous lead extraction (TLE) are highly lethal. Medical management of mediastinal hematoma following TLE may be a viable strategy in select cases.
Area of Science:
- Cardiology
- Vascular Surgery
Background:
- Transvenous lead extraction (TLE) carries a significant risk of superior vena cava (SVC) tear, a complication with a high mortality rate.
- Current treatment for SVC tear involves immediate sternotomy and repair, but strategies for managing mediastinal hematoma without hemodynamic instability remain unclear.
Observation:
- Two cases of SVC tear during TLE are presented.
- Case 1: A 60-year-old man with lead fracture and innominate vein stenosis developed a mediastinal hematoma after laser sheath extraction, with no active bleeding during surgery.
- Case 2: A 28-year-old man with lead fractures underwent mechanical sheath extraction, resulting in a mediastinal hematoma.
Findings:
- Both patients with mediastinal hematoma following TLE, despite SVC tears, were successfully managed without immediate sternotomy.
- Leads were removed using laser and mechanical sheaths, respectively.
- Mediastinal hematoma in both cases was managed medically.
Implications:
- Medical management of mediastinal hematoma after TLE-induced SVC tear may be a safe alternative to immediate sternotomy in hemodynamically stable patients.
- This approach could potentially reduce the morbidity associated with emergency sternotomy.
- Further research is warranted to define the criteria for non-operative management of SVC tears during TLE.
Introduction:
Superior vena cava (SVC) tear is the most lethal complication during transvenous lead extraction (TLE) with a mortality rate as high as 50%. Treatment involves aggressive attempts to maintain cardiac output and immediate sternotomy to localize and repair the vascular tear. Occlusion balloons have been developed to provisionally occlude the lacerated SVC and to provide hemodynamic stability allowing time for surgery. In case of mediastinal hematoma without hemodynamic instability, the strategy remains unclear.
Methods And Results:
We describe two cases of SVC tear during TLE. The first case was a 60-year-old man who presented with a right ventricular single-chamber defibrillator lead fracture and innominate vein stenosis. The RV lead was removed using a laser sheath causing a mediastinal hematoma with no active bleeding during surgical exploration few hours later. The second case was a 28-year-old man that presented with a right atrial (RA) lead fracture and RV lead insulation failure in a dual-chamber defibrillator (ICD).
Conclusion:
Both the RA and RV leads were removed with mechanical sheaths, and a mediastinal hematoma was medically managed.
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