In Reply to: Re: Case 697 01 -- Perforation of the right brachiocephalic vein posted by Al Nemcek on July 04, 1997 at 17:17:26:
Agree that the brachioephalic to svc turn is a tricky one, particularly for the inflexible peel-away sheaths that dialysis catheters are delivered through--this angle cost me nearly an hour of 'pushing' last week to pass a perm-cath around this sharp turn. All the while the patient would experience periodic right sided chest pain, presumably from pushing the peel-away and catheter against the right wall of the svc at this tight bend. I imagine that more aggressive use of force would quite readily make a hole in the inomnate or SVC-potentially an irretrievable complication. Had this occurred, I'd have probably tried to , if possible tack down the rent in the vein as quickly as possible using a bare wallstent-fast to deliver, may well work, doesn't burn any bridges regarding other percutaneous repairs. At typical SVC pressures, a small hole might in such a case, eventually stop bleeding as the tamponading mediastinal hematoma became large enough. Getting a covered stent together "quickly" to put into the lesion in this case is almost a contradiction in terms, unless one already has commercial large graft avaiable because they're at an institution that is involved in a clinical trial.
Try a bare stent first, fast.