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Semin intervent Radiol 2015; 32(04): 439-444
DOI: 10.1055/s-0035-1564795
Morbidity and Mortality
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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

David C. Stevens
1   Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
,
Sabah Butty
1   Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
,
Matthew S. Johnson
2   Department of Radiology and Surgery, Indiana University School of Medicine, Indianapolis, Indiana
› Author Affiliations
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Publication History

Publication Date:
10 November 2015 (online)

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Case Report

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.

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Fig. 1 Axial (a) and coronal (b) contrast-enhanced CT images of the chest performed 4 days prior to the attempted venous reconstruction. A spiculated right upper lobe mass (white arrow) causes near-complete occlusion of the SVC (black arrow).

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. Through-and-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.

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Fig. 2 Digital subtraction venogram obtained prior to intervention. The SVC and right brachiocephalic vein are occluded and collateral vessels (arrows) are present.
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Fig. 3 Fluoroscopic image obtained during angioplasty of the bilateral brachiocephalic veins.
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Fig. 4 Digital subtraction venogram. Contrast material in the pericardium (arrow) is indicative of SVC rupture and evolving cardiac tamponade.
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Fig. 5 Fluoroscopic image of the thorax after placement of overlapping 13 mm × 5 cm Viabahn-covered stents (arrow). An endotracheal tube is now visible.
 

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