Elsevier

Heart Rhythm

Volume 18, Issue 2, February 2021, Pages 207-214
Heart Rhythm

Clinical
Devices
Lead-related superior vena cava syndrome: Management and outcomes

https://doi.org/10.1016/j.hrthm.2020.09.006Get rights and content

Background

Superior vena cava (SVC) syndrome includes the clinical sequalae of facial and bilateral upper extremity edema, dizziness, and occasional syncope. Historically, most cases have been associated with malignancy and treatment is palliative. However, cardiac device leads have been identified as important nonmalignant causes of this syndrome. There are little data on the effectiveness of venoplasty and lead extraction in the management of these patients.

Objective

The objective of this study was to report the findings associated with the use of balloon angioplasty and lead extraction in the management of 17 patients with lead induced SVC syndrome.

Methods

Data collected from January 2003 to July 2019 identified 17 cases of SVC syndrome at our tertiary center. Their outcomes were compared to a control group of patients without SVC syndrome. A P value of <.05 was considered statistically significant.

Results

Of the 17 patients, 13 (76%) underwent transvenous lead extraction and venoplasty. Three patients (18%) were treated with venoplasty alone, and 1 patient (6%) underwent surgical SVC reconstruction. In 10 patients (59%), transvenous reimplantation was necessary. Symptom resolution was achieved in all 17 patients and confirmed at both 6 and 12 months’ follow-up. There was no significant difference in the rate of complications associated with transvenous lead extraction for SVC syndrome vs control.

Conclusion

In patients with SVC syndrome, venoplasty and lead extraction are safe and effective for resolution of symptoms and maintaining SVC patency.

Introduction

Superior vena cava (SVC) syndrome is a rare condition that can severely affect a patient’s daily functioning and quality of life. Patients present with morning facial edema, bilateral upper extremity swelling, and recurrent headaches due to impaired venous return. Historically, most cases of SVC syndrome have been associated with malignant carcinomas and poor outcomes. However, in the past 2–3 decades, there has been an increase in nonmalignant etiologies of this condition—largely attributable to cardiac implantable electronic devices (CIEDs). In these patients, stenosis is thought to develop as an inflammatory reaction to a lead making contact with the vein endothelium.1

Although up to 33% of patients with cardiac devices develop some degree of SVC stenosis, clinical symptoms rarely develop. The prevalence of SVC syndrome is estimated to be between 0.6% and 3.5%.2,3 The etiology is not yet fully understood, however there is consensus that the presence of multiple leads is one of the strongest risk factors for the development of symptoms. When symptoms do occur, they present months to years after device implantation.4 A meta-analysis by Riley et al5 of 104 patients who developed SVC syndrome found the median time to onset of symptoms to be 48 months.

SVC syndrome compromises the patency of access veins and complicates device management. The need to maintain luminal patency is particularly important in younger patients who may require multiple device upgrades in years to come. According to the 2017 Heart Rhythm Society (HRS) expert consensus,6 lead removal is a level 1 recommendation for patients with symptomatic SVC stenosis. To date, no clinical trials have investigated the effectiveness of various interventions on symptom resolution and long-term luminal patency. Thus, there are few guidelines for physicians to consult when managing these patients. In this article, we review the literature and report our findings associated with balloon angioplasty and lead extraction on the management of these patients.

Section snippets

Methods

We collected data from January 2003 to November 2019 on all patients undergoing transvenous lead extraction (TLE) at a single tertiary cardiovascular center in Miami, FL. Institutional review board approval was obtained for this study. For each case, pertinent data including demographic information, patient history, device type, procedural information, complications, and success were recorded. Our study population consists of the 17 patients referred to our center for symptomatic SVC stenosis.

Registry population

Our cohort consisted of the 17 patients who met both the clinical and radiological diagnoses of SVC syndrome between 2003 and 2019. All patients had >90% stenosis of the SVC. Per the Stanford classification system, all 17 patients had type 2 SVC occlusions.7

Thirteen of our patients underwent percutaneous lead extraction and venoplasty. One patient required surgical SVC correction because of the presence of multiple leads that were occluding the azygous vein. Three patients underwent venoplasty

Discussion

There are currently few guidelines for the management of device-induced SVC syndrome. Before the development of percutaneous interventions, surgical extraction was the primary management modality for problematic leads. Surgical techniques are associated with high rates of occlusion recurrence and significant morbidity/mortality and have fallen out of favor to percutaneous approaches.8 Occlusion recurrence for surgery is estimated to be 12%, while recurrence for percutaneous intervention is

Conclusion

This study finds that venoplasty with lead extraction is safe and effective for maintaining lumen patency at 6 and 12 months for patients with pacemaker/ICD lead-induced SVC syndrome.

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    Funding sources: The authors have no funding sources to disclose.

    Disclosures: Dr Carrillo has served as a consultant to Spectranetics (Philips), has received a research grant from St. Jude Medical (Abbot), and has served on the speakers bureau for Medtronic, St. Jude Medical (Abbot), and the Sorin Group (MicroPort). Mr Arora reports no conflicts of interest.

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