INTRODUCTION: Superior vena cava (SVC) syndrome results from obstruction of blood flow through the SVC. Lung cancer is the most common cause of it, and presents in approximately 5% of patients. Malignant obstruction is commonly treated by radiation and chemotherapy, however, stenting of the SVC is becoming the treatment of choice in many centers. Cardiac tamponade can be an infrequent but fatal complication of SVC stenting.
CASE PRESENTATION: A 70-year-old man with a previous history of non small cell lung cancer presented to his medical oncologist with shortness of breath, episodes of syncope and facial edema. His findings were suggestive of SVC syndrome and a Computed Tomography (CT) of the thorax revealed a significant narrowing of the SVC. The patient had a relatively recent radiation therapy and a SVC stent placement was recommended for symptomatic relief. Shortly after the procedure the patient had sudden onset of shortness of breath and was emergently intubated for respiratory failure. Further finding included worsening hypotension for which vasopressors were used. He was admitted to the Medical Critical Care Unit. Initial examination revealed distended jugular venous pulse (JVD) and distant heart sounds. 12 lead EKG showed sinus tachycardia and low voltage QRS complex in the limb leads. An emergent echocardiogram identified a pericardial effusion with findings suggestive of hemodynamic compromise consistent with cardiac tamponade. An emergent pericardiocentesis was done with drainage of 300 ml of blood, after which the patient's hypotension resolved and vasopressors were discontinued. Pericardial effusion hematocrit level was similar to plasma. A venogram was performed in the heart catheterization lab which showed a persistent leak at the distal end of the SVC stent into the pericardium suggestive of vascular laceration. He urgently underwent an SVC stenting at the distal end of the original stent without any further bleeding to the pericardial sac. The pericardial drain was discontinued 24 hours after it was placed and a follow up echocardiogram showed resolution of the hemopericardium. Patient was extubated 5 days later and transfered to the general medical ward for further care.
DISCUSSIONS: SVC syndrome is a frequent complication of lung cancer. Endovascular stenting is effective and becoming in many centers the treatment of choice in patients with persistent or recurrent symptoms. Low complication rates and rapid symptomatic improvement has led to its increase as the primary treatment option. Reported complications are infrequent and include stent migration, phrenic nerve compression, stent thrombosis and hemorrhage from the iliac vein trauma. Our patient presented with hemopericardium that lead to a cardiac tamponade from injury to the SVC after endovascular stenting.
CONCLUSION: Given the rarity and high mortality of this entity, cardiac tamponade should be considered in patient with sudden decompensation after SVC stenting.
DISCLOSURE: Mohammad Omari, No Financial Disclosure Information; No Product/Research Disclosure Information