Superior Vena Cava Rupture and Cardiac Tamponade Complicating the Endovascular Treatment of Malignant Superior Vena Cava Syndrome: A Case Report and Literature Review

Abstract

A 47-year-old man with known metastatic small cell lung cancer presented with 1 week of right arm swelling, facial flushing, shortness of breath, right hand weakness, and intermittent blurry vision. Physical examination revealed right upper extremity edema and facial plethora. Computed tomography (CT) of the chest confirmed enlargement of a right upper lobe mass causing near-complete occlusion of the right brachiocephalic vein and superior vena cava (SVC) (►Fig. 1), consistent with SVC syndrome (SVCS). After extensive discussion regarding the risks and benefits of the procedure, the patient elected to proceed with endovascular reconstruction of the central veins.Bilateral basilic vein access was obtained, and digital upper extremity venography confirmed near-complete occlusion of the SVC (►Fig. 2). The occlusion was traversed using a 0.035-inch wire and a 5F catheter, and intraluminal crossing was confirmed with contrast injection. Throughand-through access was obtained via the right common femoral vein, and the SVC and brachiocephalic veins were dilated using 8-and 10-mm balloons (►Fig. 3). Venogram immediately following the 10-mm angioplasty demonstrated contrast extravasation into the mediastinum and likely the pericardial space, indicative of SVC rupture (►Fig. 4). Ultrasound revealed a thin pericardial effusion, which, given the patient's history of radiation, was deemed sufficient to cause tamponade. Overlapping 13 mm  5 cm Viabahn-covered stents (Gore Medical, Flagstaff, AZ) were placed from the central aspect of the left brachiocephalic vein to the atriocaval junction (►Fig. 5). However, the patient rapidly decompensated, and despite aggressive resuscitation following advanced cardiac life support (ACLS) protocol, including pericardiocentesis, the patient expired on the table.

Gianturco Z-stent vena cava stenting potential complications in oncology

“…As a matter of fact, lifethreatening cardiac tamponade has been reported in 0.1-1.8%. 3 We also experienced cases of pulmonary edema that occurred few hours after successful procedure in elderly head and neck and lung cancer patients. The so-called overload syndrome is due to rapid increase in centripetal venous return after successful stent placement.…”

Complementary role of intervention radiology in palliative care in oncology setting

“…Other causes include thrombosis from CVCs and pacemaker leads. [5657] Although no scientific evidence exists, endovascular treatment has been proposed as a first-line treatment for malignant SVC obstruction. [5859] Similarly, obstruction of inferior vena cava (IVC) may result in pedal edema, venous ulcers, renal vein thrombosis, and/or renal insufficiency (when IVC obstruction is at or above the level of renal veins) and Budd–Chiari syndrome (when IVC obstruction is at the level of hepatic veins).…”

Endovascular Stenting in Superior Vena Cava Syndrome: A Systematic Review and Meta-analysis

“…SVCS is however increasingly caused by benign pathologies. Indwelling intravascular catheters or cardiac device leads have replaced rarer pathologies such as fibrosing mediastinitis to become the commonest benign cause of SVCS [4][5][6][7][8][9][10].…”