Idiopathic left innominate vein stenosis during pacemaker implantation with venoplasty in a retrograde approach

Retrograde venography to navigate an occluded subclavian vein to achieve cardiac resynchronization therapy upgrade via His bundle pacing: a case report

Background

Guidelines support upgrade to cardiac resynchronization therapy (CRT) through His-bundle pacing (HBP) in pacing-induced cardiomyopathy and moderate left ventricular systolic dysfunction (LVSD). Lead-related venous occlusion can represent an obstacle to upgrade procedures. We describe a technique to overcome venous occlusion through direct puncture of a collateral vein facilitating upgrade to HBP.

Case summary

An 84-year-old man with a right ventricular (RV) pacemaker was referred with New York Heart Association (NYHA) Class III breathlessness secondary to moderate LVSD (left ventricular ejection fraction [LVEF] 45%). Device interrogation revealed 100% RV pacing and AV-dyssynchrony. To optimize atrioventricular (AV) and interventricular (VV) synchrony a CRT upgrade with HBP was planned. Venography revealed an occluded left subclavian vein which was probed in a retrograde manner using a 6F MPA catheter from right femoral venous access. We were able to direct the catheter distal to the left brachio-cephalic vein and define the occlusion using contrast. A collateral branch was identified, a J-wire was left in this branch and venous access was secured at this medial subclavian site using the Seldinger technique. A right atrial lead was deployed and 69 cm ISI-1 His lead was deployed via a C315 sheath at the His-bundle. The resulted in non-selective HBP (Stim-QRS end 146 ms). There were no procedural complications. Two months later both symptoms and LV function (LVEF 55%) improved.

Discussion

Lead-related venous occlusion occurs frequently and can be probed in a retrograde manner from femoral venous access using contrast, facilitating direct percutaneous puncture of collateral venous branches to allow upgrade to CRT via HBP.

Strategy of pacemaker and electrode replacement for superior vena cava stenosis

Cardiac implantable devices are commonly used for superior vena cava stenosis, but there have been few reports of electrode replacement in the stenosed superior vena cava. A 73-year-old man was diagnosed with second-degree type II atrioventricular block and a permanent dual-chamber, rate-modulated pacing pacemaker was implanted 10 years previously. Because of depletion of the pacemaker battery and an increase in the ventricular pacing threshold, replacement of the pacemaker and ventricular electrode was required. During the operation, we found that the patient had severe superior vena cava stenosis on angiography, and this caused obstruction when a common guidewire was used to pass through the superior vena cava. After attempting various methods, we successfully passed through the vascular stenosis with a super slide guidewire and a long sheath, and completed replacement of the pacemaker and ventricular electrode. We summarize the related literature of superior vena cava stenosis related to a cardiac implantable device, and discuss the replacement strategy of this complication and other treatment options.

A Rare Cause of Difficult Catheterization to the Left Brachiocephalic Vein during Transfemoral Transvenous Embolization

Objective

We experienced a case of difficult catheterization to the left brachiocephalic vein (LBCV) during transfemoral transvenous embolization for traumatic carotid-cavernous fistula. We discussed the cause of this phenomenon.

Case Presentation

A 78-year-old woman with a traumatic carotid-cavernous fistula was treated with combined transarterial and transvenous embolization; however, catheterization to the LBCV was very difficult. A balloon guiding catheter (BGC) already placed in the left common carotid artery (LCCA) caused displacement of the LCCA and further compression of the originally stenotic LBCV.A CT investigation of 104 cases of neuroendovascular treatment in our hospital revealed that the distance between the ventral bones and the dorsal arteries sandwiching the LBCV was significantly negatively correlated with age (r = -0.41, p = 0.000020). Aging and arteriosclerotic change are possibly related to the LBCV stenosis.

Conclusion

When catheterization to the LBCV is difficult during transfemoral transvenous embolization, not only the presence of anatomical variations and stenosis or occlusion of LBCV itself but also compression from surrounding structures should be considered, especially in elderly patients. In rare cases, a catheter inserted in an adjacent artery may cause further compression of the LBCV.