Cardiac Tamponade after Stenting for Superior

Vena Cava Obstruction

Sheng-Nan Chang,1 Nai-Hsin Chi,2 Wen-Jeng Lee,3 Kuan-Lih Hsu,4 Fu-Tien Chiang4,5 and Chuen-Den Tseng4

Percutaneous transluminal stenting has been well documented in use for the treatment of superior vena cava (SVC)

obstruction. It offers relatively safe and rapid alleviation of the symptoms of SVC obstruction due to malignancy

compared with other treatment modalities. However, cardiac tamponade after stenting treatment occasionally

occurrs. Here, we present a case of 48-year-old female patient with cardiac tamponade after endovascular stenting

for malignancy-related SVC syndrome. This patient had facial swelling, headache, dysphagia and dyspnea as the

initial presentations. After clinical workup, she had SVC obstruction, due to lung cancer. She received SVC

endovascular stenting with an Easy-Wall stent. Three hours after the procedure, she developed cardiac tamponade.

An urgent operation confirmed that the protruding pin of the Wall stent had punched through the wall of the SVC and

into the aorta, which led to the complication. To avoid this unfortunate result, we suggest that for an obstruction site

in the lower half of the SVC, the lower margin of the stent should be placed protruding into the right atrium to get a

short free end in the right atrial cavity after stent expansion, so that it will not injury the SVC or the atrial wall after

stent expansion. From this case report, we can learn a possible hazard of SVC stenting and propose a technique of

stent placement to prevent cardiac tamponade.

Key Words: Cardiac tamponade � Complication � Stent � Superior vena cava obstruction

INTRODUCTION

SVC obstruction usually results from malignancy, in

85-97% of patients.1 Among the related malignancies,

pulmonary tumor has the predominance and accounts for

80% of the malignant diseases.2 The other malignant dis-

eases are lymphoma, mesothelioma, thymoma and meta-

static diseases. With the increasing usage of intravascular

devices such as pacemakers, defibrillators, hemodialysis

catheters and central venous catheters (e.g. Port-A) in

current medical practice, the etiologies of SVC obstruc-

tion unrelated to malignancy are increasing.3

The obstruction of the SVC can result from extrinsic

compression of the vascular wall or intravascular throm-

bosis formation. Regardless of either extrinsic or intrin-

sic mechanism, patients have increasing venous pressure

and therefore experience various symptoms and signs, i.e.

headache, visual disturbance, facial swelling, dsypnea,

cough, dysphagia, hoarse voice (with recurrent laryngeal

nerve involvement), chest pain, dilation of the collated

vein over the chest wall, upper extremity swelling and

syncope with altered mental status (with cerebral venous

hypertension).4,5 The diagnosis of SVC obstruction is

usually suspected by clinical evaluation at first. Further

confirmation can be made by computed tomography,

magnetic resonance imaging and venography.

To choose the appropriate treatment for SVC ob-

struction, the patient should be evaluated for the under-

lying disease. For malignancy-related SVC obstruction,

161 Acta Cardiol Sin 2009;25:161�4

Superior Vena Cava Obstruction, Cardiac TamponadeCase Report Acta Cardiol Sin 2009;25:161�4

Received: August 13, 2008 Accepted: December 15, 20081Cardiovascular Center, National Taiwan University Hospital Yun-

Lin Branch; 2Cardiovascular Division, Department of Surgery; 3De-

partment of Medical Imaging; 4Division of Cardiology, Department

of Internal Medicine; 5Department of Laboratory Medicine, National

Taiwan University Hospital, Taipei, Taiwan.

Address correspondence and reprint requests to: Dr. Chuen-Den

Tseng, Division of Cardiology, Department of Internal Medicine, Na-

tional Taiwan University Hospital, No. 7, Chung Shan South Road,

Taipei 100, Taiwan. Tel: 866-968661028; E-mail: cdtsneg@ha.mc.

ntu.edu.tw

physical position with head elevation, diuretics, steroid,

thorombolysis, radiotherapy, chemotherapy, operation

and endovascular stenting have been used to alleviate

the symptom.6 Compared with other treatment modali-

ties, endovascular stenting assumes high priority in the

current practice because of its easy procedure, safety and

rapid efficacy.2,7 However, even with the low complica-

tion rate, several hazards after stenting have been en-

countered, including cardiac tamponade.1,8 Here, we re-

port a case of cardiac tamponade following stenting for

lung tumor-induced SVC obstruction, and to avoid such

complications, we propose a strategy of stent placement

from the operative findings.

CASE HISTORY

A 48-year-old female patient had suffered from fa-

cial and neck swelling for 1 month prior to admission.

The symptoms and signs became more severe and com-

plicated with headache, dysphagia and dyspnea 1 week

before admission. Chest radiography revealed a perihilar

mass over the right lung. Computed tomography showed

that the mass was at the central part of the right upper

lobe of the lung with compression of the SVC (Figure

1A). Lymphadenopathies were noted at the right hilum,

prevascular and right paratrachea. Cardiac ultrasono-

graphy showed good heart contractility, with left ventri-

cle ejection fraction of 65% and no pericardial effusion.

To palliate the symptoms of SVC obstruction, the patient

was referred for SVC stenting.

The procedure was performed via right femoral ap-

proach under local anesthesia. The hydrophilic guide wire

(Terumo, Asahi, Japan) was introduced into the right com-

mon femoral vein through a 6-French sheath and pass to

the obstruction site smoothly. By using a JR4 diagnostic

Acta Cardiol Sin 2009;25:161�4 162

Sheng-Nan Chang et al.

Figure 1. (A) An axial CT image reveals the SVC (superior vena cava) (arrow) is compressed by the pulmonary tumor (arrow head). (B) A cava

venogram confirms the location of the obstruction (arrow). (C) Post-inflation at the middle portion of the stent. (D) Final venography reveals a

patent SVC.

A B

C D

catheter (Cordis, U.S.A.), a cava venogram was taken and

the location of the obstruction was identified (Figure 1B).

After that, direct stenting with an 16 � 60 mm Easy-Wall

stent (Boston Scientific, U.S.A.) was performed success-

fully. A XXL balloon (Boston Scientific, U.S.A.) of di-

mensions 14 � 20 mm was inflated at the middle portion of

the stent (Figure 1C) to fully expand the stent. Final

venography demonstrated a patent SVC without residual

stenosis (Figure 1D). The SVC pressure gradient decreased

from 25 mmHg to 11 mmHg after stenting. The patient felt

relief of dyspnea and headache immediately after the pro-

cedure. The procedure time was about 30 minutes. How-

ever, the patient had chest discomfort accompanied with

unstable hemodynamics. Her blood pressure decreased

from baseline 117/73 mmHg to 85/50 mmHg three hours

after stenting. Emergent treatment with inotropic agents

and hydration were given. A cardiac ultrasonography ex-

amination revealed pericardial effusion with signs of right

atrium and right ventricle compression. An urgent pericar-

diocentesis with insertion of a pig tail were performed im-

mediately. Bloody pericardial effusion of about 400 ml

was drained out. Due to persistent pericardial effusion

drainage from the pig tail catheter in the following hours

(about 100 ml/hr), the patient was referred for surgical in-

tervention three hours after pericardiocentesis under the

impression of vena cava perforation. The operative find-

ings showed an unexpectedly bleeder on the aortic wall

and a small laceration wound at the SVC. The lower mar-

gin of the stent was located a short distance above the en-

trance of the SVC into the right atrium. The pin of the

stent’s lower margin was protruding outside the SVC. The

aorta wall near the pin-whole bleeding site was erosive

(Figure 2A). After hematoma evacuation inside the peri-

cardial cavity, the aorta was repaired with prolene suture

and wrapped with hemashield graft. The SVC was also re-

paired with prolene suture. Excision of a whitish, elastic

and firm tumor was also performed during the operation.

The pathology revealed pulmonary adenocarcinoma.

DISCUSSION

In the literature, cardiac tamponade following SVC

stenting usually occurs after radiotherapy or chemother-

apy, because the vascular wall will become more fragile

when a tumor has shrinkage after irradiation or chemo-

therapy.1 Also, cardiac tamponade can take place during

the procedure of stenting because of wire penetration or

the pressure tension of balloon dilation.8 In previous

studies, acute cardial tamponade may result from inad-

vertent extraluminal traversal of the SVC in the so-

called danger zone above the right atrium,9 because in

that zone, SVC is not completely covered by serous

pericardium over a length of nearly 3.5 cm above the

right atrium, and the anatomical boundaries may also be-

come altered or obliterated by neoplasia or inflamma-

tion.9 This danger zone is also the level where the great-

est narrowing was present in our patient. Our patient

ubiquitously developed cardiac tamponade three hours

163 Acta Cardiol Sin 2009;25:161�4

Superior Vena Cava Obstruction, Cardiac Tamponade

Figure 2. (A) The protruding pin of the Wall stent punched the wall of

the SVC (white arrow). The tumor was with whitish and elastically firm

consistency (black arrow). A coronal reconstruction CT image reveals

the anatomical locations of the SVC (superior vena cava), RA (right

atrium), AO (aorta) and PA (pulmonary artery). (B) If the obstruction

site is in the lower half of the SVC, the yellow region is the danger zone.

The lower margin of the stent should avoid the danger zone. (C) If the

obstruction site is in the upper half of the SVC, the green region is the

danger zone. The lower margin of the stent should avoid the danger zone.

A

B C

after the stenting procedure. The operative findings con-

firmed that the protruding pin of the Wall stent had

punctured the wall of the SVC. The laceration wound

and pin-hole bleeder of the aortic wall might result from

the sliding motion between the protruding pin of the

stent and the aorta wall during heart beating and respira-

tory motion. This could explain why cardiac tamponade

occurred in this patient three hours later.

During endovascular stenting, there are several kinds

of stents that could be chosen at present. Self-expanding

stents, such as the Wall stent, are used in patients be-

cause of their advantages such as flexibility, intrinsic ra-

dial expansive force, and suitable for respiratory move-

ments.2 However, the pin of the Wall stent margin is free

and sharp. The pin might bend and protrude out of the

vascular wall after post-dilation. In order to prevent this

complication, the technique of stent placement should

emphasize the stent localization. Because the length of

the stent usually gets shorter by around 1-2 cm after

stent expansion, the stent localization should pay more

attention to the stent’s lower margin. For an obstruction

site in the lower half of the SVC, the lower margin of the

stent should be placed protruding into the right atrium to

get a short free end in the right atrial cavity after stent

expansion (Figure 2B). This protrusion should not be too

much to avoid injury to the cardiac wall such as was

seen in one case with cardiac tamponade due to cardiac

perforation after Port-A insertion.10 By this way, the

sharp and free margin of the Wall stent or other stent will

not punch out the wall of the vena cava after placement.

If the obstruction site is located in the higher or upper

half of the SVC (Figure 2C), it would be appropriate and

safe to place the stent end away from the aorta to avoid

the pulsating friction which might cause SVC and aortic

perforation.

This case illustrates a possible etiology of cardiac

tamponade after endovascular stenting in cases of SVC

obstruction due to lung cancer, and a technique of stent

placement is proposed for the procedure strategy in

such circumstances. In the future, an alternative stent

designed to avoid the sharp end of the Wall stent might

be another choice to avoid cardiac tamponade after

stenting.

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