Hybrid lead extraction and reconstruction of the superior vena cava and right atrium for a rare type of superior vena cava syndrome: a case report

Background: Superior vena cava (SVC) syndrome is caused by a partial or total obstruction of the SVC. In patients with vena cava syndrome due to endovascular pacemaker leads, lead extraction and endovascular stenting is the first-line treatment with high success rates. Case summary: At age 41, a patient presented with exercise intolerance and swelling of the hands and head with exertion and after sleeping in supine position. The patient had received endovascular pacemaker leads at the age of 21. Computed tomography showed a stenosis of the SVC with subtotal occlusion of the caudal part of the SVC and a large mass (likely fibrous tissue) around the pacing leads within the right atrium resulting in an upper and lower compartment of the right atrium. Since a percutaneous interventional approach was deemed unsuitable, a hybrid surgical approach with lead extraction and reconstruction of the right atrium and SVC using a bovine pericardial patch was performed. After an uneventful procedure, the patient experienced immediate symptom relief and was discharged in good condition. Discussion: Pronounced fibrous tissue can form in patients with implanted endovascular leads with the need for cardiac surgical support. Close interdisciplinary collaboration was the key to success in this hybrid approach.