Aortic Laceration Secondary to Palmaz Stent Placementfor Treatment of Superior Vena Cava Syndrome

Johanna Evans, MD,1 Ziad Saba, MD,1* Howard Rosenfeld, MD,1LeNardo Thompson, MD,2 and Roger Williams, MD3

Aortic laceration secondary to Palmaz Stent placement for treatment of superior venacava syndrome is reported. This potentially life-threatening complication should beconsidered when rigid balloon expandable stents are used to treat superior vena cavasyndrome of benign origin. Cathet. Cardiovasc. Intervent. 49:160–162, 2000.r 2000 Wiley-Liss, Inc.

Key words: Superior Vena Cava Syndrome; Palmaz-Schatz stent; aortic laceration;complication

INTRODUCTION

Superior vena cava (SVC) Syndrome, first describedby Dr. William Hunter in 1757 [1], is an obstruction offlow through the SVC caused by a variety of malignant orbenign entities [2,3]. Treatment by percutaneous deliveryof metallic stents was initially reported in 1986 [4] andsince then has been used extensively [2,4–16]. Successfulstent deployment generally results in restoration of lami-nar blood flow with early resolution of symptoms andlong-term patency of the SVC [2]. Experience withvarious stents and delivery techniques has been publishedboth in individual case reports and several small series[2,5–7]. Stent types have included self-expanding devicessuch as the Gianturco (William Cook EuropeAS, Bjaerver-skov, Denmark) and the Wallstent (Schneider Inc., PfizerHospital product groups, Minneapolis, MN), as well asballoon deployed devices such as the Palmaz stent(Johnson & Johnson Interventional Systems, Warren,NJ).

Complications are uncommon and few have beenreported [2,5,6,8–14]. These include migration or mis-placement of the stent [2,6,9], thrombotic stent occlusion[6,14], puncture of the right atrium, and pulmonaryedema [2]. The following report describes a case oflaceration of the aorta occurring shortly after placementof a Palmaz stent for treatment of SVC syndrome.

CASE REPORT

A 21-year-old woman with sickle cell disease devel-oped SVC thrombosis and subsequent SVC syndrome(with complaints of facial swelling and headaches) as acomplication of serial central venous lines required formanagement of recurrent vaso-occlusive episodes and

chronic transfusions. Thrombolysis of the SVC thrombo-sis with urokinase was previously attempted several timeswithout improvement in symptoms. An echocardiogramshowed partial SVC obstruction with probable thrombusat the right atrial superior vena cava junction, confirmedby a superior vena cavogram. After consideration ofsymptoms and the long term need for central venousaccess, the physicians and family opted for endovascularstent placement.

After surgical removal of the indwelling central venouscatheter under general anesthesia, a right heart catheteriza-tion revealed a 6-mmHg-pullback gradient from the highSVC to the right atrium. Angiographically, the superiorvena cava measured 16 mm below stenosis narrowing to11 mm in the AP projection (Fig. 1) and at most 7 mm inthe lateral projection. The right femoral venous sheathwas replaced with a long 11 French sheath and advancedinto the innominate vein. A Palmaz P308 stent (Johnson& Johnson Interventional Systems) was mounted on a 16mm in diameter and 3 cm in length Z-Med. balloon(Braun Medical Inc., Bethlehem, PA). The balloon/stentapparatus was advanced within the sheath and the sheathwas withdrawn proximal to the balloon edge. A hand

1Department of Cardiology, Children’s Hospital Oakland, Oak-land, California2Department of Cardiac Surgery, Children’s Hospital Oakland,Oakland, California3Department of Pathology, Children’s Hospital Oakland, Oak-land, California

*Correspondence to: Dr. Ziad Saba, Department of Pediatric Cardiol-ogy, Children’s Hospital Oakland, 747 52nd Street, Oakland, CA94609–1809.

Received 17 June 1999; Revision accepted 17 August 1999

Catheterization and Cardiovascular Interventions 49:160–162 (2000)

r 2000 Wiley-Liss, Inc.

injection through the side port of the sheath demonstratedoptimal positioning of the stented balloon across the areaof stenosis. The stent was inflated under fluoroscopicguidance. After stent deployment, a pullback pressuremeasurement demonstrated no residual gradient. A con-trast injection in the innominate vein showed good stentposition with a SVC diameter of 16 mm (Fig. 1B). Therewas no extravasation of contrast and the right atrial wallwas opposed to the pericardial shadow.

Catheters were removed and hemostasis was estab-lished. The patient was extubated and while beingtransported to the gurney, complained of chest pain. Her

heart rate suddenly dropped to 50 bpm with rapidprogression to ventricular fibrillation. She was immedi-ately re-intubated and CPR was initiated. Echocardio-gram revealed a large pericardial effusion. Attempts atpericardiocentesis were unsuccessful and emergent me-dian sternotomy was performed. A large pericardialeffusion of bright red blood suggestive of an arterialorigin was evacuated. At that time, a laceration in the wallof the ascending aorta was noted and repaired. Thelaceration was located at the rightward and superioraspect of the aorta, in direct opposition to the SVC stent(Fig. 2). There was no obvious tear in the SVC wall;however, the imprint of the stent could be clearly seen onthe SVC with protrusion of the edges outside the vesselwall. An incidental tear in the right atrial appendage wasnoted and repaired. A pericardial wrap was placed aroundthe SVC. Drainage of the pericardial effusion and aortarepair was followed by immediate hemodynamic stabil-ity, however the patient sustained a significant neurologi-cal insult with severe cerebral edema progressing to aherniation and death. At autopsy, the laceration in theascending aorta was confirmed and the integrity of theSVC seemed preserved with the pericardial wrap in place.

DISCUSSION

It has been postulated by several authors that, becauseof its safety and effectiveness, stent placement should be

Fig. 1. (A) Angiography of the SVC stenosis in the AP projec-tion. Double arrow indicates narrowest portion measured at 11mm. (B) Angiography of the SVC and Left Innominate veins inthe AP projection after placement of a Palmaz P308 stent. Notethat the stent is in good position with no extravasation ofcontrast seen and the atrial wall opposed to the pericardialshadow. Arrow indicates position of the stent end.

Fig. 2. Schematic representation. Arrow indicates the end ofthe stent flaring outward and in close relation to the aorta.

Aortic Laceration Secondary to SVC Stent Placement 161

the first choice treatment for patients with SVC syndrome[2,3,11,12,14]. Despite a relatively low complication rate,however, the safety of venous stent placement to treatbenign SVC syndrome has not been adequately addressedand traumatic aortic rupture is a potential, life threateningcomplication.

Architectural features inherent in currently availablestents, as well as anatomic characteristics of systemicvenous stenosis, may contribute to wall perforation anddamage of surrounding structures.

Due to differing stress characteristics across the lengthof the stent, stent expansion starts at the end of the stentand progresses inward. This causes flaring of the proxi-mal and distal stent [17]. In the thick-walled artery,stent-flaring helps to secure the device in proper position,whereas in the thin-walled systemic vein this same flaringmay contribute to vessel puncture [15,18].

Patient selection may contribute to the risk of venousperforation. Patients with stenosis due to scarring fromprior venous surgery or narrowing by external compres-sion from malignancy may carry a lower risk of perfora-tion, whereas patients with normal vein wall thicknessmay be more predisposed to vessel perforation.

In the current case, stent location (closely opposed toaortic wall), underlying physiology (sickle cell anemiawith chronic high output state and aortic dilation), and athin wall SVC obstruction combined to produce a lethalcomplication of stent deployment.

In conclusion, aortic laceration should be a consideredas a potential complication when balloon expandablestents are used in treatment of proximal SVC obstruction.

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