Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 3912  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
 Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 59  |  Issue : 11  |  Page : 758-760  

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


1 Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Web Publication20-Nov-2015

Correspondence Address:
Lakshmi Kumar
Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.170042

Rights and Permissions

How to cite this article:
Chandrashekarappa SM, Vayoth SO, Seetharaman M, Kumar L. Superior vena cava syndrome due to catheter related thrombus in a patient with a permanent pacemaker. Indian J Anaesth 2015;59:758-60

How to cite this URL:
Chandrashekarappa SM, Vayoth SO, Seetharaman M, Kumar L. Superior vena cava syndrome due to catheter related thrombus in a patient with a permanent pacemaker. Indian J Anaesth [serial online] 2015 [cited 2019 Sep 20];59:758-60. Available from: http://www.ijaweb.org/text.asp?2015/59/11/758/170042

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 2 nd 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/mm 3 . 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 1]a. 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

Click here to view


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. [2],[3] 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 1]b. 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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Venturini E, Becuzzi L, Magni L. Catheter-induced thrombosis of the superior vena cava. Case Rep Vasc Med 2012;2012:469619.  Back to cited text no. 1
    
2.
Gbaguidi X, Janvresse A, Benichou J, Cailleux N, Levesque H, Marie I. Internal jugular vein thrombosis: Outcome and risk factors. QJM 2011;104:209-19.  Back to cited text no. 2
    
3.
Yilmaz KB, Akinci M, Dogan L, Yologlu Z, Atalay C, Kulacoglu H. Central venous catheter-associated thrombosis in the perioperative period: A frequent complication in cancer patients that can be detected early with Doppler examination. Tumori 2010;96:690-4.  Back to cited text no. 3
    
4.
Rizvi AZ, Kalra M, Bjarnason H, Bower TC, Schleck C, Gloviczki P. Benign superior vena cava syndrome: Stenting is now the first line of treatment. J Vasc Surg 2008;47:372-80.  Back to cited text no. 4
    
5.
Gebreyes AT, Pant HN, Williams DM, Kuehl SP. Be aware of wires in the veins: A case of superior vena cava syndrome in a patient with permanent pacemaker. J Community Hosp Intern Med Perspect 2012;2: Doi: 10.3402/jchimp.v2i3.19159.  Back to cited text no. 5
    
6.
Debourdeau P, Farge D, Beckers M, Baglin C, Bauersachs RM, Brenner B, et al. International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer. J Thromb Haemost 2013;11:71-80.  Back to cited text no. 6
    


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed773    
    Printed10    
    Emailed1    
    PDF Downloaded203    
    Comments [Add]    

Recommend this journal