Superior vena cava syndrome after radiofrequency sinus node modification treated with thrombolysis and stent implantation.

Case Report A 30-year-old woman was admitted with symptomatic bradycardia 2 weeks after undergoing a third ablation procedure for inappropriate sinus tachycardia (IST) in another centre. A permanent pacemaker was implanted. She re-presented 3 days later with swelling of both arms, neck, and head consistent with superior vena cava (SVC) syndrome. Venography showed bilateral brachiocephalic vein thrombosis extending to the SVC. There was no symptomatic improvement with therapeutic anticoagulation for 14 days; repeat venography demonstrated increased thrombus load. Systemic thrombolysis was administered (streptokinase 250 000 U bolus followed by 100 000 U/h over 24 h). Subsequent venography confirmed the resolution of the thrombus but persistent SVC obstruction. Acombinedprocedurewasperformedtostent theSVCandtorevisethepacing system.Theatrial leadwasremovedand theventricular lead was withdrawn into the subclavian vein providing access to the left subclavian vein and a channel through the occlusion (Figure 1A). A femoral approach was used to cross the SVC obstruction and place 16 × 40 and 16 × 20 mm self-expanding stents in the stenosed segment; the second stent was required as the initial 40 mm stent did not cover the occlusion fully (Figure 1B). A new atrial lead and the existing right ventricular (RV) lead were advanced through the SVC stent to the right atrium (RA) and RV septum, respectively. Symptoms resolved within 12 h. Thepatient did not showany recurrence of symptomsor signs ofSVCsyndrome and the pacemaker is functioning well at 12 months follow-up.