Case Series and Review of Literature for Superior Vena Cava Injury During Laser Lead Extraction

Transvenous laser lead extraction poses a risk of major complications (0.19%-1.8%), notably injury to the superior vena cava (SVC) in 0.19% to 0.96% of cases. Various factors contribute to SVC injury, which can be categorized as patient-related (such as female gender, low body mass index, diabetes, renal problems, anemia, and reduced ejection fraction), device-related (including the number, dwell time, and type of leads), or procedural-related (such as reason for extraction, venous obstructions, and bilateral lead placements).

[Reconstruction of caval veins]

OBJECTIVE

To study the possibilities and results of reconstruction of caval veins.

MATERIAL AND METHODS

We analyzed the results of reconstruction of caval veins in 31 patients (19 men and 12 women) including superior vena cava (SVC) in 5 cases and inferior vena cava (IVC) in 26 cases. Penetrating wounds with vascular damage were found in 8 patients. Iatrogenic damage to IVC was observed in 19 patients (nephrectomy for kidney cancer - 2, nephrectomy for secondary kidney wrinkling - 1, echinococcectomy from retroperitoneal space - 1, adrenalectomy for adrenal tumors - 5, right-sided lumbar sympathectomy - 1, resection of abdominal aortic aneurysm - 1, resection of a large retroperitoneal tumor - 6). Iatrogenic damage to SVC occurred in 2 patients during resection of mediastinal tumor. In other 4 cases, elective surgery for mediastinal tumor (1), pancreatic head cancer (2) and liver alveococcosis (1) was accompanied by resection and replacement of caval veins.

RESULTS

All interventions for caval vein injury were performed under adequate infusion therapy. Seven (22.6%) patients died. One patient with blunt chest trauma and damage to SVC died during thoracotomy. In another patient, infrarenal IVC was intersected during mobilization of retroperitoneal hydatid cyst that required ligation for vital indications. High venous hypertension below the ligature led to eruption of sutures on the venous stump. The patient died from hypovolemia after additional IVC ligation. Other 5 patients died in early postoperative period without leaving the state of shock. These patients had damage to retrohepatic segment of IVC (1), vascular-organ (1) and iatrogenic (3) injuries. One patient died from pulmonary embolism, two patients - from venous bleeding between the 2nd and the 5th postoperative days. Patients died before reoperations. Two patients with postoperative bleeding underwent redo surgery with favorable outcomes. One patient underwent redo surgery for peritonitis with a favorable result. Thus, 7 (22.6%) patients with caval vein injury died in intraoperative and early postoperative period. Non-specific complications occurred in 4 (12.9%) patients. These events were corrected by conservative measures. Other 24 (77.4%) patients with traumatic and iatrogenic injuries of caval veins were discharged.

CONCLUSION

Caval vein injury is less common event compared to other vascular damages. Nevertheless, this complication is accompanied by severe blood loss, shock and hypovolemia. We can only assume damage to a great vessel in patients with penetrating wounds before surgery and appropriate symptoms of internal bleeding. However, final diagnosis is made during surgery. Hemostasis is a responsible and difficult surgical stage in these patients. There is usually no alternative to reconstructive surgery in these cases. However, ligation is permissible in extremely ill patients and only in infrarenal segment of IVC. Vascular suture is a more acceptable and effective option for reconstruction. However, patch repair is advisable for large defects. In our opinion, this approach is better regarding long-term patency compared to total replacement with synthetic prostheses.

Location of Superior Vena Cava Tears in Transvenous Lead Extraction

BACKGROUND

Superior vena cava (SVC) tears are rare but potentially lethal complications associated with transvenous lead extraction. When lacerations occur, surgeons need to be prepared for an emergent response. Nonetheless, little is known about the precise whereabouts of these lesions. Understanding the location and injury patterns enables a more anticipated and targeted surgical response.

METHODS

We collected data via physician interviews after an SVC laceration occurred. These physicians were identified through the US Food and Drug Administration's Manufacturer and User Facility Device Experience database and independent physician reports of adverse events. We identified 116 reports of SVC tears between July 1, 2016, and July 31, 2018. For an SVC tear to be included in our registry, a cardiothoracic surgeon had to be physically present to confirm the injury via emergent sternotomy. In each case, the surgeon recorded the SVC injury's exact location after a repair was attempted.

RESULTS

During the study period, 116 SVC tears were confirmed by sternotomy. Tears occurred in any combination of the following locations: SVC-innominate vein, body of the SVC, and SVC-right atrial junction. The majority of tears (n = 72; 62%) were located in the isolated body of the SVC, followed by the SVC-right atrial junction (n = 23;19.8%) and the SVC-innominate junction (n = 17;14.6%). Combined tears were rare, accounting for only 3.6% (n = 4) of the adverse events recorded.

CONCLUSIONS

Most SVC tears occurred in the isolated body of the SVC. The second most common location was the SVC-right atrial junction. The SVC-innominate junction was the third most common location for these injuries. Combined tears were uncommon.

Right Atrial, Right Ventricular, Superior Vena Cava Dissection Caused by Swan-Ganz Catheter Placement

This case involves Swan-Ganz catheter placement in a patient who developed cardiogenic shock, possibly due to the catheter dissecting the intimal lining of the superior vena cava and endocardium.

Long-term follow-up of endovascular repair of iatrogenic superior vena cava injury: A case report

RATIONALE

This report aimed to present the long-term follow-up results of the management of superior vena cava (SVC) rupture during balloon angioplasty in an attempt to relieve SVC obstruction as a result of hemodialysis (HD) catheter-related central vein stenosis.

PATIENT CONCERNS

We present a case of a 42-year-old woman with end-stage renal disease on HD for 4 years, initially from an autogenous fistula for 2.5 years and then from a right internal jugular vein (IJV) catheter. She presented with clinical manifestations of SVC obstruction (dilated anterior chest wall and abdominal wall veins and facial swelling), which progressed over the last 1.5 years.

DIAGNOSIS

A venogram confirmed right and left brachiocephalic vein and SVC obstruction.

INTERVENTIONS

She underwent balloon angioplasty of the SVC through the right IJV, during which the dilated area ruptured, resulting in right hemothorax and hypovolemic shock. A covered stent was placed over the bleeding site, and the patient recovered.

OUTCOMES

Rapid and skilled endovascular intervention through placement of a covered stent at the bleeding site can be lifesaving.

LESSONS

It is superior to open surgical management in terms of complexity and morbidity especially in patients who are poor surgical candidates, and its durability is proving to be comparable.

Superior Vena Cava Rupture Caused During Balloon Dilation for Treatment of SVC Syndrome Due to Repetitive Catheter Ablation

A 29-year-old woman with an implanted AAI mode permanent pacemaker, who had undergone catheter ablation for inappropriate sinus tachycardia 4 times, experienced complications of superior vena cava (SVC) syndrome. Severe stenosis of the SVC wall was observed in computed tomograms. During balloon dilation for the treatment of SVC syndrome, the SVC was ruptured, resulting in cardiac tamponade. An emergency operation was performed using percutaneous cardiopulmonary support (PCPS). A longitudinal tear 1 cm in length was identified at the junction of the right atrium and the SVC, requiring a patch plasty using an autologous pericardium 2.5 cm x 3 cm in size.

SVC rupture is a complication to be completely avoided when we perform balloon dilation for the treatment of SVC syndrome. Therefore, the indication of balloon dilation for the treatment of SVC syndrome requires critical examination and attention.

Superior Vena Cava Perforation and Cardiac Tamponade After Filter Placement in the Superior Vena Cava

The purpose of this paper is to report the complication of perforation of the superior vena cava (SVC) leading to cardiac tamponade after the insertion of a Trapease IVC filter in the SVC position. A 29-year-old man was hit by a motor vehicle and sustained numerous injuries including a left skull fracture, intracerebral hemorrhage, and left open tibial shaft fracture. During his hospitalization, he developed an extensive symptomatic right upper extremity deep venous thrombosis involving the brachial, axillary, subclavian, internal jugular, and brachiocephalic veins. Owing to an intracerebral bleed, anticoagulation was contraindicated. Therefore, a Trapease filter (Cordis Inc.) was placed in the SVC via the left subclavian vein. Four hours later, the patient became hypotensive with associated tachycardia and tachypnea. Computed tomography of his chest revealed a hematoma around the SVC, a moderate amount of fluid within the pericardium, and a moderate-sized right pleural effusion. The patient was taken to the operating room and a pericardial window was performed. Approximately 500 cc of blood was evacuated from the pericardium and immediate improvement in vital signs was noted. The patient was discharged from the hospital 2 weeks later and at 6-month follow-up had made a full recovery. This is the first case of SVC perforation leading to cardiac tamponade after the insertion of a Trapease filter. Owing to the rigid structure of the filter and associated motion of the SVC and pericardium, the Trapease filter may be contraindicated in the SVC.

Legal aspects in implantable defibrillator extraction

At the Institute of Legal Medicine in Chieti, a case of iatrogenic superior vena cava perforation was observed during laser extraction of an infected biventricular implantable cardiac defibrillator. The presentation of this particular case represented a starting point for studying the occurrence of similar complications in literature, since their knowledge and understanding should induce resolution of any organisation problems, aid in increasing physicians' training and impose the availability of cardiac surgeons during such operations.

[Syndrome of vena cava superior in the injured persons with traumatic instability of a sternocostal skeleton as a consequence of polytrauma]

There were analyzed 8 clinical observations of treatment of syndrome of vena cava superior in the injured persons in traumatic instability of a sternocostal skeleton. Peculiarities of course of traumatic process, concerning the trauma severity objective prove, were established.

Cardiac and great vessel injuries after chest trauma: our 10-year experience

BACKGROUND

Cardiovascular injuries after trauma present with high mortality. The aim of the study was to present our experience in cardiac and great vessel injuries after chest trauma.

METHODS

During the 10-year period, 104 patients with cardiac (n=94) and great vessel (n=10) injuries presented to our hospital. The demographic data, mechanism of injury, location of injury, other associated injuries, timing of surgical intervention, surgical approach, and clinical outcome were reviewed.

RESULTS

Eighty-eight (84.6%) males presented after chest trauma. The mean age of the patients was 32.5±8.2 years (range: 12-76). Penetrating injuries (62.5%) were the most common cause of trauma. Computed tomography was performed in most cases and echocardiography was used in some stable cases. Cardiac injuries mostly included the right ventricle (58.5%). Great vessel injuries involved the subclavian vein in 6, innominate vein in 1, vena cava in 1, and descending aorta in 2 patients. Early operations after admission to the emergency were performed in 75.9% of the patients. Thoracotomy was performed in 89.5% of the patients. Operative mortality was significantly high in penetrating injuries (p=0.01).

CONCLUSION

Clinicians should suspect cardiac and great vessel trauma in every patient presenting to the emergency unit after chest trauma. Computed tomography and echocardiography are beneficial in the management of chest trauma. Operative timing depends on hemodynamic status, and a multidisciplinary team approach improves the patient's prognosis.

Persistent left superior vena cava: a possible site for haemodialysis catheter placement

Persistent left superior vena cava (PLSVC) is a congenital variant of the thoracic venous system, which is associated with other congenital abnormalities. Asymptomatic cases are often diagnosed incidentally during invasive cardiovascular procedures such as the deployment of central venous access devices. It is important to be aware of the existence of a PLSVC and the clinical implications that it may pose to the proceduralist during catheter placement. We describe our experience and the lessons learnt during the placement of a haemodialysis catheter via the left internal jugular venous route in a patient with unsuspected PLSVC.

Central venous catheter-induced delayed hydrothorax via progressive erosion of central venous wall

Central venous catheter (CVC)-induced hydrothorax is a delayed complication after the placement of an indwelling subclavian or internal jugular central venous catheter. The catheter tips may cause long-lasting mechanical damages that lead to a slow erosion of the wall of the superior vena cava (SVC), thereby resulting in hydrothorax. The damage may stem from the catheter tips being positioned inappropriately or from the relocation of the catheter tip that was initially ideally positioned. We describe an 80-year-old woman with CVC-induced hydrothorax. She presented with spinal subdural hematoma and preoperatively underwent a multiple-lumen CVC insertion through her left subclavian vein. Her recovery course was uneventful after surgical hematoma removal and spinal cord decompression. However, thirty hours after the CVC placement, the patient began to suffer from an increasing dyspnea. The chest X-ray showed right-sided, massive pleural effusion and a widened mediastinum, requiring the removal of the CVC and the drainage of the pleural fluid. After these procedures, the respiratory status improved rapidly. The present case report suggests that the complication of a hydrothorax may occur after a patient's position changes, and it usually occurs in cases where the catheter tip was initially placed in the ideal position. Operators responsible for CVC placement have to be aware of this delayed complication and have the catheter tips remain in a consistently appropriate position.

Damage control: cavoatrial anastomosis during a catastrophic right intrapericardial pneumonectomy

While undergoing an intrapericardial pneumonectomy for a massive right pulmonary inflammatory pseudotumor that had invaded the mediastinum, an 18-year-old woman experienced a nearly fatal iatrogenic complication. Dense scarring adjacent to the pseudotumor had drawn in the superior vena cava posterolaterally and fused the right main pulmonary artery to the right superior pulmonary vein within the pericardium. The failure of a linear stapler to secure the pulmonary vessels led to torrential hemorrhage. Attempts to control the bleeding resulted in inadvertent superior vena cava occlusion and central venous pressure elevation. Because cardiopulmonary bypass might not have been reliably established in time to avoid irreversible cerebral ischemia, we borrowed a technique from congenital heart surgery and rapidly fashioned a cavoatrial connection. The patient survived the operation without negative neurologic or cardiac sequelae, recovered fully, and had no recurrence of the pseudotumor. Herein, we describe the intraoperative decisions that were made under intense time pressure to avert catastrophe.

Delayed vascular injury and severe respiratory distress as a rare complication of a central venous catheter and total parenteral nutrition

Complications related to central venous catheters (CVCs) in the postoperative period can be fatal. We recently had a case of bilateral pleural effusion and respiratory distress caused by delayed vascular injury. A 79-y-old Japanese woman was admitted to our hospital because of advanced gastric carcinoma. A multiple-lumen CVC was placed through the left subclavian vein 1 d before surgery for postoperative nutritional management. The patient suddenly complained of dyspnea, and the chest X-ray film revealed right massive pleural effusion. Although the patient's symptoms soon disappeared after the thoracentesis, she again developed severe respiratory distress, and an endotracheal intubation was performed and her respiration was managed by mechanical ventilation. Computed tomographic scan of the chest revealed a displacement of the tip of the CVC out of the wall of the superior vena cava, mediastinitis, and leakage of intravenous fluid, which may have been caused by delayed vascular injury due to the CVC. The CVC was removed immediately after the diagnosis of delayed vascular injury at 10 d after surgery. The patient soon recovered with conservative treatment and was discharged from the hospital 43 d after surgery. This case highlights an extremely rare presenting complication of CVC placement and total parenteral nutrition.

[Bullet embolism]

Bullet embolism is an uncommon consequence of penetrating firearm injuries, rarely observed in everyday forensic practice. The present report presents two cases of gunshot bullet embolism. The first examined case is a contact gunshot wound with the entry wound situated at the back of the victim. The wound channel terminated in the thoracic aorta, where from, in keeping with the blood flow, the bullet was transported into the left common iliac artery. The second case pertains to a gunshot in the head, with the bullet shot from a point blank range. The wound channel had a downward course and terminated in the superior vena cava at the level of the pericardium, where from the bullet was transported down the inferior vena cava to the right femoral vein.

Superior vena cava perforation in a child from a lawnmower projectile

Lawnmowers are one of the most frequent causes of mutilating injuries to children. The majority of accidents are caused by negligence of the operator. Most injuries of this type are caused by direct contact with the spinning blade and, less frequently, by projectiles propelled by the blade. Such projectiles usually produce bruises, but can penetrate skin and soft tissues. This report presents a 6-year-old child who suffered a small, outwardly insignificant puncture wound of the chest from a lawnmower-propelled projectile who presented with fever and chest pain the following day. The diagnostic work up and treatment of this deceptively life-threatening wound are discussed.

Endovascular repair of an iatrogenic superior vena caval injury: A case report

We present the case of a patient with an iatrogenic injury to the superior vena cava during a central venous catheter placement. The vena cava was perforated when a left subclavian dialysis catheter was placed. The perforation in the right side of the vena cava occurred at the confluence of the innominate veins. This perforation was successfully repaired using a 10 mm Viabahn stent graft (W. L. Gore, Flagstaff, Ariz) delivered through a femoral approach. The stent graft was deployed as the dialysis catheter was removed. This case demonstrates the utility of stent graft repair of the superior vena cava in emergency situations.

Superior Vena Cava Rupture during Balloon Angioplasty and Stent Placement to Relieve Superior Vena Cava Syndrome: A Case Report

Percutaneous stenting of the superior vena cava (SVC) has been an accepted therapy for SVC syndrome for more than a decade. Complications are uncommon and usually of minor consequence. Three previous reports have described ruptures of the SVC during venoplasty with death on one occasion. We report a fourth case of SVC rupture during angioplasty and stenting that required immediate pericardiocentesis followed by open surgical repair via sternotomy for direct control and repair. An algorithm for rapid recognition and prompt intervention is described.

[Superior vena cava syndrome: Catheter association as a rare cause]

HISTORY AND FINDINGS

A 78 year-old-woman was admitted with a swollen face, edema of the lower eyelids and dyspnea. The past medical history revealed an ovarian carcinoma treated with polychemotherapy. Half a year before the patient had been investigated for similar clinical symptoms but no underlying cause had been detected. The histology of an enlarged axillary lymph node did not show a malignancy. The symptoms persisted after angioedema-inducing drugs had been discontinued.

INVESTIGATIONS

Initial CT scan, magnetic-resonance tomography as well as positron emission tomography failed to explain the clinical findings. Also, testing of serological, immunological and endocrinological tests as well as the differential blood count did not reveal a likely cause of the clinical symptoms. However, 4 weeks later, a repeat CT scan showed a stenosis of the superior vena cava (SVC) establishing the diagnosis of an SVC syndrome.

TREATMENT AND COURSE

The port catheter tipp was localized horizontal to the vena cava superior and was touching the vein wall. Removal of the catheter and subsequent balloon dilatation of the stenosis immediately lead to a reduction of the eyelid swelling.

CONCLUSIONS

Hence, in a case of an SVC-syndrome, complete stenosis caused by an implanted venous access system should be considered though it is rare.

Découverte tardive chez un patient de réanimation d'une perforation de la veine cave supérieure par un cathéter veineux sous-clavier

Perforation is a central venous catheterization complication mainly observed in children. Usually, patients develop sudden shock early after catheterization. We report an asymptomatic and delayed superior vena cava perforation after subclavian venous adult catheterization discovered by contrast injection tomography.

Accidental extravascular insertion of a subclavian hemodialysis catheter is signaled by nonvisualization of catheter tip

Subclavian hemodialysis (HD) catheter placement under fluoroscopy with perforation of the superior vena cava (SVC) is a rare complication that needs to be recognized and treated appropriately. We report the case of a 47-year-old black woman under treatment for end-stage renal disease secondary to HIV-associated nephropathy who sustained an extravascular insertion of fluoroscopy-guided subclavian catheterization for HD. Subsequent successful removal of the extravascularly placed catheter along with repair of the lacerated SVC were effected by open thoracic surgery.

Fatal haemothorax following large-bore percutaneous cannulation before liver transplantation

Percutaneous bypass catheters are routinely used for veno-venous bypass (VVBP) during orthotopic liver transplantation (OLT). The recognized risks include bleeding, injury of vascular and nerve structures and lymphatic leakage. We describe a case where there were difficulties during catheterization and the patient suffered a cardiac arrest on commencing VVBP. Post-mortem examination revealed the bypass catheter tip in the pleural space and a large right haemothorax. Possible mechanisms of vascular perforation and preventative measures are discussed.

Caval Perforation with Bronchial Communication: A Rare Complication of Long-term Venous Access

Superior vena cava (SVC) perforation with bronchial communication is a very rare complication of long-term venous access. A patient recently presented with erosion of a venous port catheter into a bronchus, with infusion of medications into the bronchus and associated SVC syndrome. A high position of the catheter tip against the wall of the SVC and the beveled style of cut on the catheter tip contributed to this complication. A unique combination of percutaneous techniques was helpful in managing this complication, and surgery was avoided.

The widened mediastinum in trauma patients

Mediastinal widening is a frequent radiological finding in the emergency department patient. The causes of mediastinal widening can be divided into traumatic and nontraumatic mediastinal widening. An important association of moderate to high velocity trauma is the mediastinal haematoma. It may be the result of traumatic transsection of the aorta, or it may be due to bleeding from other mediastinal vessels. Before the era of multidetector spiral CT, angiography was the gold standard for the evaluation of patients with a widened mediastinum. Meanwhile, angiography as a risk-carrying invasive examination has widely been replaced by MDCT. However, conventional radiography remains an important diagnostic tool; so does angiography, especially in the context of interventional radiology. Multidetector spiral CT plays an important role (Alkadhi et al., Radiographics 2004; 24:1239-1255), but usually as a second line procedure. This article discusses the radiological signs of traumatic mediastinal widening. Different traumatic lesions resulting in a widened mediastinum are presented, and some nontraumatic causes of a widened mediastinum are shown, in order to facilitate the differentiation between both entities.

Balloon Dilation of the Superior Vena Cava (SVC) Resulting in SVC Rupture and Pericardial Tamponade: A Case Report and Brief Review

Stent placement is an accepted primary treatment for SVC syndrome. Balloon dilation is frequently performed prior to stent placement. Although various stent-related hemorrhagic complications have been reported, as well as reports of iatrogenic catheter and guidewire perforations, there has been only one previous report of balloon dilation-related SVC rupture. We report a second case, including the clinical scenario, in the hope that should this complication occur, it might be recognized quickly and treated successfully.

Shunt atricova A propósito de dos casos: Report of two cases

The mortality of grade V and VI liver trauma fluctuates between 30% and 70%. The atriocaval shunt, described by Shrock et al, in 1968, is a therapeutic option that, after being installed, allows to repair the suprahepatic veins and retrohepatic cava in a bloodless surgical field. Its use requires an experienced and skilled surgeon to obtain survival rates similar to those obtained with other methods. We report two male patients of 17 and 18 years old treated successfully with this technique after suffering a blunt and a penetrating liver trauma by a shotgun, respectively.

Delayed presentation of totally avulsed right superior vena cava after extraction of permanent pacemaker lead

Pacemaker lead extraction has been shown to be an effective and safe treatment for infected permanent pacemaker leads, however, they may lead to potentially serious complications, usually occurring during the extraction procedure. This report describes a case of a 48-year-old woman with a patent persistent left SVC and an infected permanent pacemaker lead of a DDD pacing system who underwent transvenous laser-assisted lead extraction using a combined SVC and femoral approach. Two days after the procedure the patient developed symptoms of SVC obstruction requiring surgical intervention. The right SVC was found to be almost completely destroyed with only a thin strip of the lateral wall intact and active bleeding. The probable causative mechanisms and surgical management are discussed.

The Use of Cardiopulmonary Bypass During Resection of Locally Advanced Thoracic Malignancies

The use of cardiopulmonary bypass (CPB) for locally advanced thoracic malignancies is highly controversial. The purpose of this study was to document the techniques and results of CPB to facilitate the resection of complex thoracic malignancies and to identify common themes that provided for successful outcomes. This was a retrospective study that took place from January 1992 to September 2002. Fourteen consecutive patients (median age, 59 years; age range, 18 to 69 years; seven men and seven women) underwent CPB during the resection of locally advanced thoracic malignancies at two Boston hospitals. CPB was planned in 8 of 14 patients (57%) with centrally located tumors, while 6 of 14 patients (43%) required emergent institution of CPB due to injury of the superior vena cava (2 patients), inferior vena cava (2 patients), or pulmonary artery (2 patients). Complete microscopic resection was achieved in 12 of 14 patients (86%). The operative mortality rate was 1 of 14 patients (7%) due to pulmonary embolism (ie, the elective group). The median ICU and hospital lengths of stay were 5 and 9 days, respectively. The overall 1-year, 3-year, and 5-year survival rates were 57%, 36%, and 21%, respectively. The planned use of CPB to facilitate complete resection of thoracic malignancies should be considered only after careful patient selection. The availability of CPB also provides a safety net in the event of injury to vascular structures during tumor resection.

[Thoracic stab wound caused by a grilling scewer with defomration of the tool]

Injuries by meat- or barbecue-skewers are rarely relevant as cause of death. Besides accidental injuries they are used as coincidental tools in capital crimes. Skewers are non-typical stabbing tools of pointed-squared structure, which need considerable force to penetrate the skin. The authors report on a 42-year-old man's fatal thorax stab injury, which he sustained during a barbecue and which stretched from the left mamilla into the back right shoulder tissue. Death was caused by exanguination following stabbing through the superior vena cava. At issue was the question what amount of force was necessary to inflict the wound. Based on the deformation of the stabbing tool, as a result of a material-technical expertise, compressive load application in longitudinal direction and a stabbing force of between 120 to 665 N were to be assumed. Furthermore, in addition to the features of a non-typical tool, the autopsy findings allowed to conclude a powerful stabbing.

Surgical experience with right atrial-aortic fistula and penetration of the superior vena cava by a protruding Accufix atrial J-shaped retention wire

A 57-year-old woman who had a dual chamber pacemaker implanted in June 1990 for sick sinus syndrome had developed heart failure since 1993. Although fluoroscopy revealed that the proximal J-shaped retention wire of the lead had fractured and had protruded through the outer insulation in 1994, and also that the distal J-shaped retention wire of the lead had protruded through the outer insulation in 1997, a transthoracic echocardiographic examination diagnosed tricuspid valve regurgitation, suggesting that the right atrial-aortic fistula might have been overlooked. In an attempt to avoid migration of the J-shaped retention wire from the lead and to repair the tricuspid regurgitation, it was decided that an operation be performed; however, intraoperative transesophageal echocardiography showed a right atrial-aortic fistula. Intraoperative inspection also revealed that the right atrial-aortic fistula and penetration of the superior vena cava had been caused by the Accufix atrial J-shaped retention wire. Under total cardiopulmonary bypass and induced cardiac arrest, a right atriotomy was performed and the atrial and ventricular leads were removed from the tips. The atrial orifice of the fistula and the aortic orifice were closed. Finally, a new dual-chamber pacing system with bipolar epicardial pacing leads was implanted. Postoperative inspection revealed that the proximal retention wire had fractured, the tip of the retention wire had protruded through the outer insulation, and the distal J-shaped outer insulation was damaged.

[Acute contralateral hemothorax after cannulation of the left subclavian vein for hemodialysis]

Contralateral hemothorax after subclavian vein cannulation is a rare complication of this procedure. We report one case of acute contralateral hemothorax due to perforation of the superior vena cava during left subclavian vein cannulation for hemodialysis. Perforation was attributed to the forced insertion of the skin dilator, which was accidentally pushed too far. Chest pain began immediately after perforation and was followed, a few minutes later, by hemodynamic instability. The signs and symptoms described in this report may serve to warn of the possibility of this complication.

Late superior vena cava perforation and aortic laceration after stenting to treat superior vena cava syndrome secondary to fibrosing mediastinitis

We describe a case of late perforation of the superior vena cava and laceration of the ascending aorta after stent implantation for superior vena cava syndrome. The etiology of the late perforation is unclear, and could be secondary to either flaring of the trailing edge of the stent or chest trauma.

[Differential diagnosis of left-sided thoracic venous catheters: case report of a persistent left superior vena cava]

The differential diagnosis of left-sided thoracic central venous catheters is discussed in context with the cannulation of a persistent left superior vena cava. In this case the catheter tip was seen lying to the left of the spine on frontal chest X-ray. In addition to the descending aorta, differential diagnoses are a persistent left-sided superior vena cava as well as other smaller veins such as the left internal thoracic vein, the left superior intercostal vein, or the pericardiophrenic vein. The misplacement of a venous catheter in a pericardiophrenic vein may result in a fatal pericardial tamponade.

Complications associated with optical-access laparoscopic trocars

OBJECTIVE

To investigate the number and type of serious complications associated with optical-access trocars reported by sources other than the medical literature.

METHODS

Optical-access trocars, first introduced in 1994, were designed to decrease the risk of injury to intra-abdominal structures by allowing the surgeon to visualize abdominal wall layers during placement. To date, very few complications with their use have been reported in the medical literature. MEDLINE, the Food and Drug Administration's Medical Device Reporting, and the Manufacturer and User Facility Device Experience databases were searched for reports of complications occurring during the use of optical-access trocars for laparoscopic access.

RESULTS

Only two serious complications resulting from the use of optical-access trocars (vena cava injuries) have been reported in the medical literature. However, 79 serious complications using these techniques have been cited in the Medical Device Reporting and Manufacturer and User Facility Device Experience databases since 1994. These include 37 major vascular injuries involving aorta, vena cava, or iliac vessels, 18 bowel perforations, 20 cases of significant bleeding from other sites, three liver lacerations, and one stomach perforation. Four of these complications resulted in patient deaths.

CONCLUSION

Optical-access trocars may be associated with significant injuries despite having the ability to visualize tissue layers during insertion.

Infected mediastinitis secondary to perforation of superior vena cava by a central venous catheter

We describe the first case of infected mediastinitis associated with central venous catheter insertion. The rare occurrence of this complication may be explained by the fact that it results from central venous catheter-related bloodstream infection and catheter perforation of superior vena cava. The symptoms of this complication (chest pain, dyspnoea) are not specific. Diagnosis should be confirmed by chest x-ray and computerized tomography which show hydromediastinum and pleural effusion. Removal and subsequent culture of the catheter tip will confirm infection. Appropriate antibiotic therapy, guided by sensitivities of the cultured organisms, should be commenced. Any pleural effusion should be drained by thoracocentesis, and the pleural fluid cultured. In case of fever, bacteraemia or shock, a thoracotomy to drain mediastinal and pleural effusions may be considered.

[Perforation of the superior vena cava due to unrecognized stenosis. Case report of a lethal complication of central venous catheterization]

We report on a case of fatal perforation of the superior vena cava. The perforation occurred after catheterization of the left internal jugular vein with a hemodialysis catheter, due to an unrecognised stenosis of the superior vena cava. Vascular trauma induced by a previous, also left-sided, subclavian vein-hemodialysis catheter (in place for 14 days), seemed to be the most likely pathomechanism of the stenotic lesion. It should be emphasised that this is a frequent complication especially of left-sided dialysis catheters. In the case described a stenosis was complicated by a misdirected second hemodialysis catheter. Although being repositioned under fluoroscopic control via a guide wire, an extravasal placement occurred but was unrecognised. In order to rule out catheter misplacement, the position of every central venous catheter has to be controlled. Standard methods are either chest X-ray or right atrial electrocardiography. Additionally, confirmation of correct intravenous placement requires a combination of free venous backflow of all lumen and/or blood gas analysis or venous pressure monitoring. Only a combination of tests gives ample certainty as each test for itself has its pitfalls. After placement of hemodialysis catheters, in particular left-sided catheters, we demand chest X-ray in order to verify that the catheter runs parallel with the long axis of the superior vena cava. In doubtful cases the threshold for contrast-enhanced angiographic control of the catheter should be low. If a perforation by the catheter is suspected it should be ruled out by computed tomographic scanning or transesophageal echocardiography.