Superior vena cava syndrome due to catheter related thrombus in a patient with a permanent pacemaker.

Sir,

A 59-year-old lady was scheduled for excision of a cyst in the right lobe of the liver. She was hypertensive on irregular medication and hypothyroid on tab thyroxine 50 μg/day. Four years earlier, she needed a permanent dual chamber pacemaker implant for symptomatic sick sinus syndrome through the left subclavian vein and was not on any antiplatelet medication. Anaesthesia was induced as per the standard protocol. Radial arterial line and epidural catheter were placed before induction and right internal jugular vein (IJV) cannulated with 7.5 Fr (Arrow®) triple lumen catheter at the first attempt after intubation. The procedure was converted to an open procedure after 3 h of laparoscopy. After an uneventful 7 h intraoperative period, the patient was extubated and shifted to postoperative Intensive Care Unit.

On 2nd post-operative day, the patient complained of blurring of vision and dizziness. On examination, oedema of her face and right upper limb were noted. Her mentation was normal and there was no evidence of involvement of cranial nerves. The fundoscopic examination was unremarkable except for pallor of bilateral optic discs. Investigations were normal other than haemoglobin of 8.2 g/dL; platelet count was 135,000/mm3. A duplex ultrasound revealed a dilated right IJV with an echogenic thrombus partially filling the lumen while IJV proximal to the thrombus was normal. The left sided IJV and subclavian vein were normal. A computerised tomography scan confirmed a thrombus extending from right IJV to subclavian vein and superior vena cava (SVC) [Figure 1a]. The central venous catheter (CVC) was removed and enoxaparin dosage increased from a prophylactic dose of 20 mg once daily to a therapeutic dose 40 mg twice daily. The patient's visual symptoms normalised in 24 h and oedema of the face and hand improved. She was discharged after a week on oral anticoagulation and advised follow-up.

Figure 1

(a) Internal jugular vein partly occluded with thrombus, (b) central venous catheter alongside pacemaker lead

A catheter related thrombus (CRT) develops when the thrombus originating from an indwelling catheter extends into the vessel outside the CVC and obstructs the flow within the vein. Complications associated with CRT are infection, loss of catheter function, pulmonary embolism and postthrombotic syndrome.[1] Thrombosis of IJV is commonly reported with indwelling catheters in patients with underlying malignancies or prothrombotic states although the mean duration of indwelling catheters reported was much longer.[23] Among the non-malignant causes pacemaker wires, mediastinal fibrosis and indwelling catheters have been implicated. SVC syndrome is caused by obstruction of blood flow in SVC. Although classically described in patients with lung malignancies, it is increasingly being recognized with benign associations and with the use of indwelling catheters. These patients present with swelling of face and upper extremity, dizziness, breathlessness and dilated veins in the neck and chest wall.[4]

Our patient had developed CRT and features of SVC syndrome even with near optimal positioning of the CVC [Figure 1b]. Pacemaker leads can rarely cause SVC syndrome by causing repeated trauma and endothelial disruption.[5] However in our patient, the lumen of the left subclavian with the lead was normal. We presumed that the CVC alongside the pacemaker lead could have acted as a nidus coupled with stasis in the flow during laparoscopy predisposing to the development of IJV thrombus. There is no clear evidence for the removal of the catheter in CRT but the risks of pulmonary embolism appear minimal even with CRT.[6] We removed the CVC on account of her symptoms and intensified her treatment with low molecular weight heparin after removing the epidural catheter followed by oral vitamin K antagonists. We wish to highlight this case to ensure vigilance in the development of SVC syndrome in patients with pacemaker wires when CVCs are used in the perioperative period.

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