Lead-associated Superior Vena Cava Syndrome

Figure 1:. Photographs of the patient described in this case report taken at the time of presentation. She noted the development of subacute facial plethora, periorbital edema, neck fullness, inframammary venous engorgement, and inframammary ecchymosis. In certain cases of SVC syndrome, recruitment of collateral thoracic circulation can be mistaken for caput medusa, which is typically associated with liver disease.

Figure 2:. Baseline ECG captured in 2015 notable for normal sinus rhythm with T-wave inversions in the right precordial leads, consistent with the diagnosis of ARVC.

Figure 3:. Computed tomography angiography was performed in Argentina. A and B: Transverse slices showing a dilated azygos vein and azygos arch (solid arrow) as well as a stenotic SVC with possible thrombus (dashed arrow). C: Coronal section showing the RV ICD lead coursing through a stenotic SVC (dashed arrow).

Figure 4:. Intravascular ultrasound images of the SVC were created immediately post–lead extraction (A) and following serial venoplasty (B). The immediate post–lead extraction image is notable for a stenotic SVC with intraluminal thrombus (solid arrow). Following three serial venoplasty balloon dilations, the SVC was noted to be expanded (B). The azygos vein is visualized in both images (see asterisk).

Figure 5:. Digital subtraction angiography performed during the procedure. A: Post–lead extraction, prevenoplasty angiogram depicting the stenotic SVC with collateral mediastinal vessels. B: Post–lead extraction, postvenoplasty angiogram depicting improved SVC expansion and flow.

Figure 6:. The pre–lead extraction presenting ECG demonstrating normal sinus rhythm with persistent T-wave inversions in the right precordial leads. As compared with the 2015 baseline EKG (Figure 2), QRS amplitude was reduced in both the limb and precordial leads. Of note, the single premature ventricular complex seen on this 12-lead tracing has a left-bundle, left-superior axis likely originating from the right ventricle.

Figure 7:. A comparison between front images of the patient taken pre–lead extraction (A) and two weeks post–lead extraction with venoplasty (B). The post–lead extraction image shows resolution of the periorbital edema, facial plethora, and neck fullness that were previously noted.