Author + information
- Received October 15, 2013
- Accepted October 24, 2013
- Published online July 1, 2014.
- Michael D. Seckeler, MD, MSc∗ (, )
- Chet Villa, MD and
- Russel Hirsch, MD
- ↵∗Reprint requests and correspondence:
Dr. Michael D. Seckeler, Department of Pediatrics (Cardiology), University of Arizona, 1501 North Campbell Avenue, Post Office Box 245073, Tucson, Arizona 85724.
A 15-year-old male patient underwent removal of chronic mediastinal histoplasmosis with residual superior vena cava (SVC) stenosis and brachiocephalic vein (BCV) obstruction. He developed significant dizziness following surgery that was attributed to an inability to increase pre-load during activity. He underwent catheterization for attempted percutaneous BCV recanalization.
Under general anesthesia, vascular access was obtained in the right femoral and left subclavian veins. Simultaneous contrast injections in the SVC and BCV revealed SVC narrowing and a 12-mm gap between the veins with decompressing venous flow (Fig. 1, Online Video 1). The SVC was stented from the femoral approach.
From the subclavian vein, a 56-cm trans-septal needle in a 7-F introducer sheath was advanced, while staining with contrast, across the fibrous tissue from the BCV to SVC. The tract was dilated with a 7-mm Conquest balloon (Bard Peripheral Vascular, Tempe, Arizona), stented with a 7-mm × 22-mm Atrium iCAST covered stent (Atrium Medical Corporation, Hudson, New Hampshire), and post-dilated with a 9-mm Conquest balloon. Final angiography demonstrated flow from the BCV into the SVC with diminished collateral flow (Fig. 2, Online Video 2). There were no procedural complications. He was discharged on clopidogrel 75 mg daily and warfarin with a target international normalized ratio of 2 to 2.5.
There was a marked improvement in symptoms. Follow-up venous ultrasound and Doppler demonstrated continued patency of the connection with no gradient (Fig. 3).
Occluded systemic central veins pose a therapeutic challenge. Surgery and balloon angioplasty have modest acute success with frequent restenosis (1,2), whereas percutaneous vascular stenting provides higher rates of long-term patency (3). Successful percutaneous recanalization of occluded central systemic veins, with the aim of normalizing ventricular pre-load, is possible with careful mapping and understanding of the surrounding tissue substrate. Careful follow-up and anticoagulation is vital to ensure continued patency of recanalized vessels.
For supplemental videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 15, 2013.
- Accepted October 24, 2013.
- American College of Cardiology Foundation
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