Percutaneous treatment of superior vena cava obstruction following transvenous device implantation

Percutaneous management of superior vena cava syndrome in patients with cardiovascular implantable electronic devices

BACKGROUND

There is no consensus regarding the optimal management of cardiovascular implantable electronic device (CIED)-related superior vena cava (SVC) syndrome.

OBJECTIVE

We report our experience with transvenous lead extractions (TLEs) in the setting of symptomatic CIED-related SVC syndrome.

METHODS

We reviewed all TLEs performed at a high-volume center over a 14-year period and identified patients in which TLE was performed for symptomatic SVC syndrome. Patient characteristics, extraction details, percutaneous management of SVC occlusions, and clinical follow up data were analyzed.

RESULTS

Over a 14-year period, more than 1600 TLEs were performed. Of these, 16 patients underwent TLE for symptomatic SVC syndrome. The mean age was 53.1 ± 12.8 years, and 9 (56.3%) were men. Thirty-seven leads, with a mean dwell time of 5.8 years (range 2-12 years), were extracted. After extraction, 6 patients (37.5%) received an SVC stent. Balloon angioplasty was performed before stenting in 5 cases (31.3%). There was 1 major complication (6.3%) due to an SVC tear that was managed surgically with a favorable outcome. Eleven patients underwent reimplantation of a CIED. Over a median follow-up of 5.5 years (interquartile range 2.0-8.5 years), 12 patients (75%) remained free of symptoms.

CONCLUSION

Combining TLE with the percutaneous treatment of symptomatic SVC syndrome is a safe and viable treatment strategy.

Implantable Cardioverter-Defibrillators in Patients with ESRD: Complications, Management, and Literature Review

Background:

Cardiovascular diseases are the leading cause of death among dialysis pa-tients, accounting for about 40% of all their mortalities. Sudden cardiac death (SCD) is culpable for 37.5% of all deaths among patients with end-stage renal disease (ESRD). Implantable cardioverter-defibrillators (ICDs) should be considered in dialysis patients for the primary or secondary preven-tion of SCD. Recent studies on the implementation of ICD/cardiac resynchronization therapy do not exclude patients with ESRD; however, individualized decisions should be made in this group of pa-tients. A thorough evaluation of the benefits of ICD implementation in patients with ESRD requires several large-scale mortality studies to compare and follow up patients with ESRD with and without ICDs. In the present study, we sought to determine and clarify the complications associated with ICD implementation and management thereof in patients suffering from ESRD.

Methods:

To assess the complications allied to the implementation of ICDs and their management in patients with ESRD, we reviewed available related articles in the literature.

Results and Conclusions:

ICD implementation in dialysis patients has several complications, which has limited its usage. Based on our literature review, the complications of ICD implementation can be categorized as follows: (1) Related to implantation procedures, hematoma, and pneumothorax; (2) Re-lated to the device/lead such as lead fracture and lead dislodgment; (3) Infection; and (4) Central vein thrombosis. Hence, the management of the complications of ICDs in this specific group of patients is of vital importance.

Cardiovascular implantable electronic devices in hemodialysis patients: prevalence and implications for arteriovenous hemodialysis access interventions

Cardiovascular implantable electronic devices (CIEDs) are frequently utilized in hemodialysis patients. CIED leads are typically implanted via the subclavian vein resulting in stenosis and venous hypertension. We studied 1235 chronic hemodialysis patients under the care of our nephrology practice. For each, we determined the presence of a CIED, indication for implantable cardioverter-defibrillator (ICD), and type of hemodialysis access. Records were reviewed to identify all interventions performed on the access circuit and the central veins specifically. A CIED was present in 129 patients (10.5%), including ICDs in 75 (6.1%) and pacemakers in 54 (4.4%). The access circuit intervention rate was 1.48/access year (AY) and was similar when a CIED was ipsilateral (1.53/AY) or contralateral (1.44/AY) to arteriovenous access (p = 0.477). The rate of central venous interventions was greater in the ipsilateral (0.59/AY) versus contralateral group (0.28/AY), (p < 0.001). Fifty-four of 59 patients with ipsilateral access and CIED required <2 interventions per AY, but six failed angioplasty and required access ligation. None had superior vena cava stenosis requiring intervention. We conclude that there is a high prevalence of CIEDs in our HD patients. Ipsilateral CIED and arteriovenous access results in higher central venous intervention rates compared with contralateral cases; overall access circuit intervention rates are similar.

[Superior vena cava syndrome induced by pacemaker probes, 12 years after introduction]

Superior vena cava syndrome is a rare disease, most often found to result from a malignant process, which causes extrinsic compression of the superior vena cava. In recent years, there has been an increase of superior vena cava syndrome related to medical devices (implantable site, pacemaker [PM], central venous line for parenteral nutrition...). We report the case of a 37-year-old patient who developed a superior vena cava syndrome 12 years after implantation of a PM. The diagnosis was established on venography after two negative venous-CT focused on the superior vena cava. The superior vena cava syndrome improved immediately after angioplasty and stenting covering the PM probes at the superior vena cava/brachiocephalic venous trunk junction.

Percutaneous Transvenous Angioplasty of Left Innominate Vein Stenosis Following Right Side Permanent Pacemaker Implantation- A Left Femoral Vein to Left Axillary Vein Approach

Central venous stenosis after the insertion of a permanent pacemaker is a well recognized complication. This late complication is encountered when there is a need to change the pacemaker lead or extract it. We describe a young male who had such a complication after many years after right side pacemaker implantation. The lesion was managed percutaneously leading to placement of a new lead from the left side.

Central Vein Stenosis or Occlusion Associated with Cardiac Rhythm Management Device Leads in Hemodialysis Patients with Ipsilateral Arteriovenous Access: A Retrospective Study of Treatment Using Stents or Stent-Grafts

Purpose

Symptomatic central vein stenosis commonly occurs when cardiac rhythm management device (CRMD) leads are placed via the subclavian vein ipsilateral to arteriovenous (AV) hemodialysis (HD) access. The purposes of this study were to determine the outcomes, complications, and patency following stenting of CRMD lead-associated central vein stenosis or occlusion, and to determine the effect of stents on CRMD function.

Methods

Fourteen HD patients with AV access and an ipsilateral CRMD were treated with stents for symptomatic central vein stenosis or occlusion following inadequate response to angioplasty from January 2005 to December 2009. Subsequent access interventions, complications, and outcomes were reviewed retrospectively. Cardiology records were examined to assess CRMD function.

Results

Treatment of stenosis or occlusion with angioplasty and stenting resulted in 100% procedural success and no complications. At 6 and 12 months, respectively, primary patency rates were 45.5% and 9.0%; primary-assisted patency rates were 90.9% and 80.0%; secondary patency rates were 100% and 90.0%. There were 42 repeat interventions performed in 12 patients; five received additional stents. The mean number of subsequent interventions was 3.2 per patient (2.1 per patient-year). All CRMD testing demonstrated normal function with no device or lead failure. Seven of the 14 subjects died resulting in a 35.3% annual mortality rate. No deaths were attributable to dysrhythmia or CRMD failure and no patient required CRMD removal or exchange.

Conclusions

Placement of stents for CRMD lead-associated stenosis or occlusion yields high success and low complication rates with no effect on CRMD function. Patency rates are similar to those reported in other series of central venous stents.

Cranial Vena Caval Thrombosis Associated With Endocardial Pacing Leads in Three Dogs

Three dogs were examined several years following implantation of transvenous, single-lead, endocardial, right-ventricular permanent pacing systems for signs consistent with cranial vena caval syndrome. Angiograms performed in all dogs revealed filling defects within the cranial vena cava and, in some instances, intracardiac filling defects. Medical therapy was instituted in two dogs, with one surviving several weeks. One dog underwent surgery to address intra-cardiac thrombosis but did not survive the immediate postoperative period. Postmortem examinations were performed in two dogs and confirmed cranial vena caval and intracardiac thrombosis. Cranial vena caval thrombosis associated with transvenous pacing leads appears to carry significant morbidity and mortality.

Two Cases of Silent Superior Vena Cava Syndrome associated with Vascular access and End-Stage Renal Disease

Due to the unavoidable use of indwelling devices and the magnitude of the operative problems encountered, Superior Vena Cava Syndrome (SVCS) has become a serious threat for patients with a history of multiple catheter placements. True diagnosis sometimes is not available due to paucity of symptoms or due to the inadequate considerations of the disease. Particularly in patients with chronic kidney disease, the evidence of central venous occlusion dictates the avoidance of placing peripheral dialysis access in this extremity. In this article, we report two patients (case 1- a patient with end stage renal disease and case 2 - a patient with chronic kidney disease) with silent SVCS related to stenosis resulting from indwelling pacemaker leads. Furthermore, the first patient had an extrinsic factor of compression, a brachial artery pseudoaneurysm - which although it was not causative - it may certainly have contributed to the development of SVCS. The brachial artery pseudoaneurysm restricted even more the flow to cephalic vein and consequently to superior vena cava. Though pacemaker leads have been well identified previously in the literature as a cause of the SVCS, the brachial artery pseudoaneurysm causing extrinsic compression constitutes a novel factor. Through the publication of this paper the awareness of SVCS in these patients shall be definitely enhanced. Moreover, physicians, nurses and patients shall be educated regarding the requirement for peripheral vein presentation in chronic kidney disease.

Venous Obstruction After Pacemaker Implantation

BACKGROUND

Central vein leads are known to predispose to venous obstruction. Although usually asymptomatic, obstruction may render electrode removal difficult. This study aimed at quantifying changes in venous calibers in a prospective fashion by intravenous contrast venography (ICV) before and after pacemaker (PM) or cardioverter-defibrillator implantation.

METHODS

One hundred and fifty (mean age 67; 61% male) consecutive patients were enrolled, and followed for 6 months. A successful ICV was done at baseline prior to implantation and at 6-month follow-up in 136 (91%) patients. Minimum (D(min)) and maximum (D(max)) vessel diameters were obtained from both ICVs. A new stenosis was defined as a 50% diameter reduction in a venous segment when compared to baseline. We implanted a total of 230 electrodes: 47 (34.6%) single lead, 84 (61.8%) 2-lead, and 5 (3.7%) 3-lead systems.

RESULTS

At baseline ICV, 10 patients (7%) were found to have venous anomalies, including 8 patients with obstructive lesions, 1 patient with a persistent left superior vena cava, and 1 patient with double axillary vein. At 6 months, a new obstructive venous lesion had developed in a total of 19 (14%) patients, none of whom exhibited any local symptoms. Of these patients 14 (10%) had a stenosis (mean D(min) 4.6 mm and diameter 38% of baseline), and 5 (3.6%) had a complete venous occlusion. In most cases the new stenosis developed in a location where the vessel was narrowest at baseline. Clinical predictors for the development of stenosis were atrial fibrillation at baseline and biventricular PM implantation.

CONCLUSIONS

This is the first systematic study to quantify venous changes after PM or ICD implantation. Our study shows that venous anomalies rendering PM implantation difficult are not infrequent. The incidence of new venous obstruction was 14%. Atrial fibrillation and biventricular PM implantation were independent predictors of venous obstruction.

Severe Superior Vena Cava Syndrome after Transvenous Pacemaker Implantation

Superior vena cava syndrome is a rare complication after pacemaker implantation. The present report outlines how underestimation of clinically relevant symptoms of superior vena cava syndrome early after pacemaker implantation may result in severe complication with the need for major surgical intervention. Superior vena cava syndrome should be diagnosed early because immediate thrombolytic therapy is effective in the majority of patients and avoids the requirement for interventional or surgical efforts.