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Superior Vena Cava Obstruction
CORRESPONDENCE
4. Overton MC, Derrick J, Snodgrass SR: Surgical management of superior vena cava obstruction To the Editor: complicating ventriculo-atrial shunts. J Neurosurg 25:164, 1966 In their otherwise very thorough review of the superior vena cava syndrome due to benign causes 5. Prozan GB, Shippey RE, Madding FG, et al: Pulmonary thromboembolism in the presence of an (Superior Vena Cava Obstruction: A Review of the endocardiac pacing catheter. JAMA 206:1564,1968 Literature and Report of 2 Cases due to benign Intrathoracic Tumors, Ann Thorac Surg 20:344, 1975), 6. Williams DR, Demos NJ: Thrombosis of superior vena cava caused by pacemaker wire and managed Gomes and Hufnagel neglected to mention the effects with streptokinase. J Thorac Cardiovasc Surg of chronic intravascular foreign bodies. Thrombosis 68:134, 1974 of the superior vena cava, leading to its obstruction, and thrombosis of the deep venous system of the arm have been reported several times in association with permanent transvenous cardiac pacemaker electrodes Insertion of Hancock Xenograft [l-3, 61, and lesser degrees of thrombosis-on occaTo the Editor: sion associated with pulmonary embolism [3,5]-are more common. Within the past year we have encoun- It is usually pointless to quibble about minor technitered symptomatic late deep venous thrombosis (1 cal details; however, I believe the hazard posed by a month to 2% years following pacemaker implanta- maneuver recommended in a recent article (Stefanik tion) in 3 of 150 patients with permanent pacemakers et al, A method for insertion of a stented xenograft being followed regularly in our clinic. In a paper ap- valve in the atrioventricular position. Ann Thorac pearing in this issue (p 166) Stoney and his associates Surg 21:166, 1976) warrants comment. In the past five years my associates and I have report that more than one-third of their patients having elective pacemaker replacment were found by implanted more than 250 Hancock porcine valves in venography to have ipsilateral innominate venous the mitral position and some 25 in the tricuspid posiobstruction with well-developed collaterals. Only tion. We have not found it a problem to avoid snaring 21% of their patients with a permanent transvenous a suture on the struts of the stent. After all sutures are electrode in place for 24 months or longer had normal placed on the annulus and through the sewing ring, venograms. Similarly, the incidence of thrombosis on they are held straight with gentle tension. It is then transvenous ventriculoatrial shunts for hydro- quite simple to tilt the valve and to advance it "far edge down" until that edge contacts the rim of the cephalus may approximate 40% [41. When an intravascular foreign body is present in atrioventricular orifice. Usually the far strut will lie the superior vena cava in a patient who develops the inside the ventricle at that stage. The other two struts symptoms and signs of superior vena caval obstruc- are clearly exposed and can be inserted into the vention, the possible etiological role of the foreign body tricle under direct vision, easily avoiding entrapment should be considered prior to undertaking an exten- of sutures. Finally, as a last precaution, once the valve is seated and before a n y sutures are tied, the cusps can sive work-up for more serious occult pathology. be gently opened and the two hidden struts examined G . Frank 0 . Tyers, M . D . from inside the valve with a small dental mirror (10 Edward H . Williams, M . D . mm diameter). The third strut is clearly visible withCarolyn R. W i n e , M . D . out the mirror. We have never found a trapped suture but still continue this practice because of the cataDivision of Cardiovascular Surgery strophic consequences that could result if entrapment Deparment of Surgery did occur. In that event, it would be simple to unseat T h e Milton S . Hershey Medical Center the valve and reposition it. Hershey, PA 17033 I strongly oppose the suggested technique of suturReferences ing the struts for two obvious reasons: someone is 1. Friedman SA, Berger N, Cerruti NM, et al: Venous going to injure one or more of the delicate cusps when thrombosis and permanent cardiac pacing. Am cutting out the retaining suture, and placing the suHeart J 85:531, 1973 ture on the fabric covering of the stent risks tearing 2. Griepp RB, Daily PO, Shumway NE: Subclavian- the fabric or weakening a suture line of the stent axillary vein thrombosis following implantation of cover. Either of these serious injuries would be difa pacemaker catheter in the internal jugular vein. J ficult to detect. Thorac Cardiovasc Surg 60:889, 1970 Two of the major characteristics of the Hancock 3. Kaulbach MG, Krukonis EE: Pacemaker valve are the precision and care with which it is aselectrode-induced thrombosis in the superior sembled and the delicacy of the natural tissue cusps. vena cava with pulmonary embolization: a compli- Every effort must be made to avoid injury to the cusps cation of pervenous pacing. Am J Cardiol26:205, or damage to the stent assembly. We carefully clean 1970 our gloves; while placing sutures we hold the valve
Superior Vena Cava Obstruction
207
4. Overton MC, Derrick J, Snodgrass SR: Surgical management of superior vena cava obstruction To the Editor: complicating ventriculo-atrial shunts. J Neurosurg 25:164, 1966 In their otherwise very thorough review of the superior vena cava syndrome due to benign causes 5. Prozan GB, Shippey RE, Madding FG, et al: Pulmonary thromboembolism in the presence of an (Superior Vena Cava Obstruction: A Review of the endocardiac pacing catheter. JAMA 206:1564,1968 Literature and Report of 2 Cases due to benign Intrathoracic Tumors, Ann Thorac Surg 20:344, 1975), 6. Williams DR, Demos NJ: Thrombosis of superior vena cava caused by pacemaker wire and managed Gomes and Hufnagel neglected to mention the effects with streptokinase. J Thorac Cardiovasc Surg of chronic intravascular foreign bodies. Thrombosis 68:134, 1974 of the superior vena cava, leading to its obstruction, and thrombosis of the deep venous system of the arm have been reported several times in association with permanent transvenous cardiac pacemaker electrodes Insertion of Hancock Xenograft [l-3, 61, and lesser degrees of thrombosis-on occaTo the Editor: sion associated with pulmonary embolism [3,5]-are more common. Within the past year we have encoun- It is usually pointless to quibble about minor technitered symptomatic late deep venous thrombosis (1 cal details; however, I believe the hazard posed by a month to 2% years following pacemaker implanta- maneuver recommended in a recent article (Stefanik tion) in 3 of 150 patients with permanent pacemakers et al, A method for insertion of a stented xenograft being followed regularly in our clinic. In a paper ap- valve in the atrioventricular position. Ann Thorac pearing in this issue (p 166) Stoney and his associates Surg 21:166, 1976) warrants comment. In the past five years my associates and I have report that more than one-third of their patients having elective pacemaker replacment were found by implanted more than 250 Hancock porcine valves in venography to have ipsilateral innominate venous the mitral position and some 25 in the tricuspid posiobstruction with well-developed collaterals. Only tion. We have not found it a problem to avoid snaring 21% of their patients with a permanent transvenous a suture on the struts of the stent. After all sutures are electrode in place for 24 months or longer had normal placed on the annulus and through the sewing ring, venograms. Similarly, the incidence of thrombosis on they are held straight with gentle tension. It is then transvenous ventriculoatrial shunts for hydro- quite simple to tilt the valve and to advance it "far edge down" until that edge contacts the rim of the cephalus may approximate 40% [41. When an intravascular foreign body is present in atrioventricular orifice. Usually the far strut will lie the superior vena cava in a patient who develops the inside the ventricle at that stage. The other two struts symptoms and signs of superior vena caval obstruc- are clearly exposed and can be inserted into the vention, the possible etiological role of the foreign body tricle under direct vision, easily avoiding entrapment should be considered prior to undertaking an exten- of sutures. Finally, as a last precaution, once the valve is seated and before a n y sutures are tied, the cusps can sive work-up for more serious occult pathology. be gently opened and the two hidden struts examined G . Frank 0 . Tyers, M . D . from inside the valve with a small dental mirror (10 Edward H . Williams, M . D . mm diameter). The third strut is clearly visible withCarolyn R. W i n e , M . D . out the mirror. We have never found a trapped suture but still continue this practice because of the cataDivision of Cardiovascular Surgery strophic consequences that could result if entrapment Deparment of Surgery did occur. In that event, it would be simple to unseat T h e Milton S . Hershey Medical Center the valve and reposition it. Hershey, PA 17033 I strongly oppose the suggested technique of suturReferences ing the struts for two obvious reasons: someone is 1. Friedman SA, Berger N, Cerruti NM, et al: Venous going to injure one or more of the delicate cusps when thrombosis and permanent cardiac pacing. Am cutting out the retaining suture, and placing the suHeart J 85:531, 1973 ture on the fabric covering of the stent risks tearing 2. Griepp RB, Daily PO, Shumway NE: Subclavian- the fabric or weakening a suture line of the stent axillary vein thrombosis following implantation of cover. Either of these serious injuries would be difa pacemaker catheter in the internal jugular vein. J ficult to detect. Thorac Cardiovasc Surg 60:889, 1970 Two of the major characteristics of the Hancock 3. Kaulbach MG, Krukonis EE: Pacemaker valve are the precision and care with which it is aselectrode-induced thrombosis in the superior sembled and the delicacy of the natural tissue cusps. vena cava with pulmonary embolization: a compli- Every effort must be made to avoid injury to the cusps cation of pervenous pacing. Am J Cardiol26:205, or damage to the stent assembly. We carefully clean 1970 our gloves; while placing sutures we hold the valve
Superior Vena Cava Obstruction
207