Symptomatic venous thrombosis of the upper extremity complicating permanent transvenous pacing: reversal with streptokinase infusion

Subclavian Vein Stenosis: A Potentially Serious Complication in Chronic Hemodialysis Patients with Permanent Cardiac Pacemakers

We report on two hemodialyzed patients in whom subclavian and brachiocephalic vein stenosis secondary to permanent cardiac pacemakers led to massive congestive edema of the same arm after arteriovenous fistula/grafts were created. Therapeutic solutions regarding hemodialysis access are discussed in these patients with permanent pacemakers requiring hemodialysis.

Initial experience with a laser sheath to extract chronic transvenous implantable cardioverter-defibrillator leads

This is the first study of the use of a laser sheath to remove chronic transvenous implantable cardioverter-defibrillator leads. A 16Fr laser sheath was used to extract 14 leads from 11 patients, 6 of whom had undergone failed previous extraction attempts using conventional tools.

[Phlebitis of the upper limbs on pacemaker electrodes. 4 cases and review of the literature]

We report four cases of deep venous thrombosis of the upper extremity, which occurred in two women and two men (mean age 79 years) in whom a pacemaker electrode had been inserted 4 years on averages previously. In three of these four cases phlebitis developed after immobilization of the limb containing the electrode. Deep venous thrombosis of the upper extremity is rare, but 28% of catheterizations are responsible for phlebitis. One to 3% of patients fitted with a pacemaker have symptomatic phlebitis, but these figures rise to 28-65% when phlebography is systematically performed in subjects wearing a pacemaker. The clinical signs are the same as those of the classical forms, and the diagnosis is made by doppler-ultrasonography and by phlebography which informs on the collateral circulation. Cure is obtained with efficient anticoagulant therapy. These cases prompt us to prescribe a preventive subcutaneous heparin therapy in those pacemaker-fitted subjects whose arm is immobilized. The heparin dosage remains to be determined precisely.

Venous complications after insertion of a transvenous pacemaker

We reviewed the incidence, clinical features, current diagnostic evaluations, and treatments of venous complications that can occur after implantation of a transvenous pacemaker. Of the approximately 80 published articles on the potential venous complications after implantation of a permanent transvenous pacemaker, we selected 63 that addressed the clinical features, diagnosis, and treatment of pacemaker lead-induced venous thrombosis, which occurs in approximately 30 to 45% of patients early or late after implantation of a transvenous pacemaker. Most patients with chronic deep venous thrombosis remain asymptomatic because of the development of an adequate venous collateral circulation. Clinical features of pacemaker lead-induced deep venous thrombosis, although rare, are easily recognized. They should be sought routinely during follow-up of all patients with transvenous pacemaker leads because venous obstruction can interfere with intravenously administered therapy, monitoring of central venous pressure, and revision of a pacemaker lead. Acute deep venous thrombosis is likely to be symptomatic. Early recognition and treatment of acute deep venous thrombosis may help to decrease the potential morbidity and mortality. The definitive diagnosis of pacemaker lead-induced venous thrombosis necessitates contrast-enhanced or digital subtraction venography. Management includes anticoagulation, thrombolytic therapy, surgical intervention, and, recently, percutaneous transluminal balloon venoplasty and depends on the duration, extent, and site of venous occlusion as well as the accompanying symptoms.

Fibrinolytic therapy for venous thrombosis

In the treatment of DVT fibrinolytic therapy offers the possibility of rapid clot dissolution resulting in symptomatic relief of the acute episode as well as preservation of venous valve function and prevention of long-term disability from chronic venous insufficiency. A review of published studies comparing fibrinolytic therapy with SK to anticoagulation alone indicates that substantial venographic improvement occurs in 45% of SK treated patients compared with only 5% receiving only anticoagulation. Substantial data indicate a high incidence of venous valvular dysfunction and eventual development of chronic venous insufficiency in patients with extensive leg DVT treated with anticoagulants alone. The available data on the long-term benefits of thrombolytic therapy in preventing chronic venous insufficiency suggest that fibrinolytic therapy reduces long-term morbidity. Because best results are obtained by treatment soon after the onset of symptoms, it follows that the postphlebitic syndrome can be best avoided by prompt thrombolytic therapy of patients with acute DVT. Bleeding complications are more frequent after thrombolytic therapy than anticoagulant therapy, but most are related to invasive vascular procedures and can be minimized by proper patient selection and management. Available studies of rt-PA in treatment of DVT indicate that infusion durations of 24 hours or more may be required; further studies will be needed to evaluate the response to rt-PA compared with those of SK or UK. Thrombosis of the axillary/subclavian veins of the upper extremity, occurring spontaneously or in association with indwelling venous catheters, also respond well to regional or systemic fibrinolytic therapy, which may reduce the likelihood of developing chronic arm symptoms related to venous insufficiency.

Extraction of implanted transvenous pacing leads: a review of a persistent clinical problem

Within a few months of implantation, permanent pacemaker leads become ensheathed in fibrocollagenous tissue. This tissue may anchor the lead so that it is difficult, dangerous, or impossible to remove it. Leads with bulbous or finned tips are particularly resistant to extraction. The risks of applying traction to an entrapped lead include induction of bradycardia or ventricular tachycardia and fibrillation, invagination of the right ventricle, avulsion of the right ventricular myocardium or tricuspid valve, hemopericardium, and cardiac tamponade. Forceful traction may result in uncoiling of the conductor, disruption of the insulation, or complete fracture, leaving an intravascular remnant that may embolize or be a source for thrombosis. Although fixation and abandonment of an inactive chronically implanted lead is frequently appropriate and is known to pose little long-term risk, the retained inactive lead may interact adversely with a new active lead and then increase the risk of venous thrombosis, serve as a potential nidus for infection, or produce spurious electrical sensing signals that may be sensed by the pulse generator. Absolute indications for lead removal are those in which there would be a life-threatening situation if the lead were to remain in situ. In the absence of an absolute indication, the decision to proceed with extraction must be made by weighing the potential for serious morbidity or mortality against risks of the extraction technique. Techniques for lead removal include traction and open cardiotomy operations. When a portion of the lead is intravascular, forceps, snares, baskets, countertraction, or lead-transection devices may be used to retrieve the fragment.

Deep venous thrombosis of the upper extremity: diagnosis and treatment

Deep vein thrombosis of the upper extremity was long thought to be a benign disease, rarely complicated by pulmonary embolism and associated with minimal long-term morbidity. More recent observations have demonstrated however, that a significant number of patients will continue to have disabling symptoms after treatment with conservative measures and standard anticoagulation therapy, and that pulmonary embolism can occur in the course of the disease. Because of its significant morbidity and increasing incidence, an aggressive emergency department approach to diagnosis and early consideration of fibrinolytic therapy are recommended.

Right atrial thrombus and recurrent pulmonary emboli secondary to permanent cardiac pacing--a case report and short review of literature

A patient with a right atrial thrombus and recurrent pulmonary emboli secondary to permanent pacemaker insertion is described. Possible precipitating factors were damage to the subclavian vein, congestive heart failure, paroxysmal atrial fibrillation, and immobilization. Venography demonstrated a large atrial thrombus in the superior vena cava and right atrium. The patient was successfully treated with heparin and subsequently with warfarin and dipyridamole.

Low-dose streptokinase thrombolysis of axillary-subclavian vein thrombosis

Nine patients with 10 episodes of acute axillary-subclavian vein thrombosis were treated with local low-dose streptokinase infusion. All patients except one were heparinized during the procedure with conversion to oral anticoagulation upon completion of the infusion. Recanalization was achieved in 7 patients (70%). Thrombosis recurred in 1, and in 2 patients the procedure was unsuccessful. No major complications were encountered. We concluded that local low-dose streptokinase infusion is a safe, simple, and effective method for treating acute axillary-subclavian vein thrombosis.