Successful stent implantation for superior vena cava injury during transvenous lead extraction

Introduction The increased number of implantations of pacemaker and implantable cardioverter-defibrillator (ICD) devices has also generated a rise in the number of lead extraction procedures, with an estimated 10,000 to 15,000 devices extracted annually worldwide. The difficulty of lead extraction is directly proportional to the severity of the fibrotic and adhesive scar tissue that encases the lead, vascular endothelium, and cardiac chambers. In long-standing leads, calcification can occur. Although a traction and countertraction approach has traditionally been used to facilitate extraction, current methodology favors adding laser-assisted lead extraction to dissect through the fibrosis. Pulses of ultraviolet light are delivered fiberoptically to the distal end of the sheath, promoting sheath advancement. Transvenous extraction with laser sheaths can be performed, with a reported clinical success rate in excess of 95%. However, with or without laser assistance, the risk of complications include death, bleeding, vascular tear, cardiac avulsion, pulmonary embolism, and pericardial effusion. A recent Cleveland Clinic study of catastrophic complications occurring during transvenous lead extraction demonstrated 25 cases (0.8%) over a 16-year period that required emergent surgical or endovascular intervention. The majority (64%) of deaths and injuries were the result of laceration of the right atrium, superior vena cava (SVC), or innominate vein. Tears in the SVC usually prompt sudden hemodynamic compromise associated with high mortality and generally necessitate immediate surgical intervention. Several cases of SVC rupture have been described in the literature, including a few that were managed successfully with endovascular