Subclavian venoplasty by the implanting physicians in 373 patients over 11 years

When and how to perform venoplasty for lead placement

Because of the increasing use of cardiac implantable electronic devices (CIEDs) with one or more intracardiac electrodes, the rate of lead failure is increasing. Moreover, upgrade of the CIED frequently is indicated for cardiac resynchronization therapy or other reasons. Both these situations require a new intervention, preferably using ipsilateral venous access. However, venous obstruction after CIED insertion occurs in 10%-20% of patients and poses a major obstacle for implantation of additional leads. Possible solutions include lead extraction, contralateral lead insertion, and venoplasty. Preprocedural venoplasty is associated with the lowest short- and long-term risks. Here we describe a step-by-step approach to this technique, which can be introduced and safely performed in most interventional catheterization laboratories.

A novel approach for venous occlusion after endocavitary leads. The balloon-assisted tracking technique

The balloon-assisted tracking technique can be useful in short venous occlusions that conventional venoplasty fails. This technique could be feasible and with an expected low complication rate.

Incidence, Treatment, and Outcomes of Symptomatic Device Lead-Related Venous Obstruction

BACKGROUND

The incidence and clinical impact of lead-related venous obstruction (LRVO) among patients with cardiovascular implantable electronic devices (CIEDs) is poorly defined.

OBJECTIVES

The objectives of this study were to determine the incidence of symptomatic LRVO after CIED implant; describe patterns in CIED extraction and revascularization; and quantify LRVO-related health care utilization based on each type of intervention.

METHODS

LRVO status was defined among Medicare beneficiaries after CIED implant from October 1, 2015, to December 31, 2020. Cumulative incidence functions of LRVO were estimated by Fine-Gray methods. LRVO predictors were identified using Cox regression. Incidence rates for LRVO-related health care visits were calculated with Poisson models.

RESULTS

Among 649,524 patients who underwent CIED implant, 28,214 developed LRVO, with 5.0% cumulative incidence at maximum follow-up of 5.2 years. Independent predictors of LRVO included CIEDs with >1 lead (HR: 1.09; 95% CI: 1.07-1.15), chronic kidney disease (HR: 1.17; 95% CI: 1.14-1.20), and malignancies (HR: 1.23; 95% CI: 1.20-1.27). Most patients with LRVO (85.2%) were managed conservatively. Among 4,186 (14.8%) patients undergoing intervention, 74.0% underwent CIED extraction and 26.0% percutaneous revascularization. Notably, 90% of the patients did not receive another CIED after extraction, with low use (2.2%) of leadless pacemakers. In adjusted models, extraction was associated with significant reductions in LRVO-related health care utilization (adjusted rate ratio: 0.58; 95% CI: 0.52-0.66) compared with conservative management.

CONCLUSIONS

In a large nationwide sample, the incidence of LRVO was substantial, affecting 1 of every 20 patients with CIEDs. Device extraction was the most common intervention and was associated with long-term reduction in recurrent health care utilization.

Proposed strategies to overcome venous occlusion in the implantation of a cardiac implantable electronic device: A case report and literature review

This case report describes a successful balloon venoplasty to overcome a total occlusion from the brachiocephalic vein to the superior vena cava in a patient undergoing cardiac resynchronization therapy. It is crucial for implanting physicians to be familiar with strategies to overcome venous occlusion in lead implantation, especially balloon venoplasty, which is an effective and safe approach.

New Insights in Central Venous Disorders. The Role of Transvenous Lead Extractions

Over the last decades, the implementation of new technology in cardiac pacemakers and defibrillators as well as the increasing life expectancy have been associated with a higher incidence of transvenous lead complications over time. Variable degrees of venous stenosis at the level of the subclavian vein, the innominate trunk and the superior vena cava are reported in up to 50% of implanted patients. Importantly, the number of implanted leads seems to be the main risk factor for such complications. Extraction of abandoned or dysfunctional leads is a potential solution to overcome venous stenosis in case of device upgrades requiring additional leads, but also, in addition to venous angioplasty and stenting, to reduce symptoms related to the venous stenosis itself, i.e., the superior vena cava syndrome. This review explores the role of transvenous lead extraction procedures as therapeutical option in case of central venous disorders related to transvenous cardiac leads. We also describe the different extraction techniques available and other clinical indications for lead extractions such as lead infections. Finally, we discuss the alternative therapeutic options for cardiac stimulation or defibrillation in case of chronic venous occlusions that preclude the implant of conventional transvenous cardiac devices.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

"Retained wire femoral lead removal and fibroplasty" for obtaining venous access in patients with refractory venous obstruction

BACKGROUND

Patients with wire and catheter refractory venous occlusion are traditionally referred for pectoral transvenous lead extraction (TLE) to obtain venous access. TLE causes 1-2 mm circumferential mechanical or laser destruction of tissue surrounding the lead(s). This not only exposes the patient to the risk of major complications but also can damage nontargeted leads. We present a series of patients where retained wire femoral lead removal and fibroplasty was used to obtain venous access in patients with refractory obstruction.

METHODS

Between 2008 and 2021, we identified 17 patients where retained wire lead removal followed by fibroplasty was used to retain venous access. Demographic and procedural data were obtained by retrospective review of patient charts.

RESULTS

We were able to successfully obtain venous access in all 17 patients in whom this technique was attempted. In two patients the target lead was less than or equal to 1 year old. In the remaining 15 patients, the average dwell time of the target lead(s) was 6 years. There were no procedure-related complications, and no changes in the parameters of other leads were noted.

CONCLUSION

Retained wire femoral lead removal and fibroplasty is safe and highly efficacious at obtaining venous access in patients with refractory venous occlusion. If the target lead(s) is less than or equal to 1 year old, this technique can help obtain venous access at the time of the initial surgery, hence avoiding the need for TLE. Furthermore, in patients referred for TLE to obtain venous access, this technique by avoiding the use of TLE tools spares the patient of the associated risks.

Comparative Analysis of Procedural Outcomes and Complications Between De Novo and Upgraded Cardiac Resynchronization Therapy

OBJECTIVES

This study compared rates of procedural success and complications between de novo cardiac resynchronization therapy (CRT) implantation versus upgrade, including characterization of technical challenges.

BACKGROUND

CRT upgrade is common, but data are limited on the incidence of procedural success and complications as compared to de novo implantation.

METHODS

All patients who underwent a transvenous CRT procedure at a single institution between 2013 and 2018 were reviewed for procedure outcome, 90-day complications, reasons for unsuccessful left ventricular lead delivery, and the presence of venous occlusive disease (VOD) that required a modified implantation technique.

RESULTS

Among 1,496 patients, 947 (63%) underwent de novo implantation and 549 (37%) underwent device upgrade. Patients who received a device upgrade were older (70 ± 12 years vs. 68 ± 13 years; p < 0.01), with a male predominance (75% vs. 66%; p < 0.01) and greater prevalence of comorbidities. There was no difference in the rate of procedural success between de novo and upgrade CRT procedures (97% vs. 96%; p = 0.28) or 90-day complications (5.1% vs. 4.6%; p = 0.70). VOD was present in 23% of patients who received a device upgrade and was more common among patients with a dual-chamber versus a single-chamber device (26% vs. 9%; p < 0.001). Patients with and without VOD had a similar composite outcome of procedural failure or complication (8.0% vs. 7.8%; p = 1.0).

CONCLUSIONS

Rates of procedural success and complications were no different between de novo CRT implantations and upgrades. VOD frequently increased procedural complexity in upgrades, but alternative management strategies resulted in similar outcomes. Routine venography before CRT upgrade may aid in procedural planning and execution of these strategies.

Navigating Challenging Left Ventricular Lead Placements for Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) is a mainstay in the management of heart failure patients with electrical dyssynchrony. Left ventricular (LV) lead positioning remains an important variable that predicts the response to CRT. Anatomical and technical challenges can hinder optimal LV lead placement using traditional lead implantation approaches. Knowledge of normal anatomical variants and common anomalies is essential for successful LV lead implants. With advancements in tools and techniques for LV lead delivery, the implanting electrophysiologist can target the optimal LV pacing site, rather than accepting a suboptimal location that is less likely to provide clinical benefit. In this review, we discuss various challenges to achieving optimal LV lead implantation and present strategies to overcome them.

Wire countertraction for sheath placement through stenotic and tortuous veins: The “body flossing” technique

Background

Innominate vein stenosis and venous tortuosity are common findings during cardiac implantable electronic device upgrades or replacements and present a challenge to the implanting physician. Various techniques have been described to facilitate lead placement, including serial dilation, balloon venoplasty, and percutaneous access medial to the stenosis, each with its own benefits and risks.

Objective

The purpose of this study was to assess the feasibility, safety, and efficacy of the wire countertraction (“body flossing”) technique to facilitate sheath placement through tortuous and stenotic vessels.

Methods

Patients undergoing cardiac implantable electronic device procedures requiring the body flossing technique due to inability to place vascular sheaths over the wire through stenoses or tortuosity were retrospectively analyzed. Clinical characteristics, procedural equipment, and outcomes were analyzed.

Results

Simultaneous countertraction was successful in all attempted cases, including 8 patients with stenoses and 2 with tortuosity. In 2 of the stenosis cases, venoplasty had previously failed. No complications occurred.

Conclusion

Simultaneous countertraction (body flossing) is an effective tool to overcome venous stenosis and tortuosity that are amenable to wire advancement but not to vascular sheaths. It seems to be a safe and effective alternative to other techniques used in these scenarios.

Hybrid venous recanalization and cardiac implantable electronic device lead revision procedures: A single-center retrospective analysis of 38 patients

PURPOSE

The purpose of this study was to describe the safety and efficacy of hybrid recanalization procedures in a series of patients with obstructed central veins requiring cardiac implantable electronic device (CIED) revision.

METHODS

Between 2008 and 2016, 38 consecutive patients (24 M; age 60.5 ± 16.2 years; range 25-87 years) with central venous obstruction underwent 42 recanalization interventions performed in conjunction with CIED revision or extraction. Fifty percent of patients (19/38) presented with veno-occlusive symptoms, and 13% (5/38) of patients had CIED leads with an ipsilateral upper extremity dialysis conduit.

RESULTS

Ninety-one percent (38/42) of all procedures resulted in successful recanalization and CIED revision. Twenty-four percent (9/38) of all patients required secondary procedures due to recurrent stenosis, and 78% (7/9) of those requiring secondary procedures had indwelling dialysis conduits and/or clinical symptoms related to venous occlusion before the initial procedure. There were complications in 2 patients related to recanalization, and in 3 related to CIED revision.

CONCLUSIONS

Recanalization of central venous stenosis/occlusion in patients with CIED can be technically challenging but is successful in most patients. Symptomatic patients and those with dialysis conduits often require more aggressive revascularization interventions and may be at increased risk of complication or need for secondary interventions.

Challenging Implants Require Tools and Techniques Not Tips and Tricks

The EP Clinics article "How to implant CRT devices in a busy clinical practice" describes the basics of the "interventional telescoping technique". This article focuses on specific circumstances where the tools and techniques are invaluable: (1) inability to locate the coronary sinus (CS), (2) inability to advance a catheter into the CS, (3) patients with CS atresia, (4) unstable CS access, (4) angulated target veins, (5) small and/or tortuous target veins, (6) target veins into which a wire cannot be advanced, (7) target veins with a drain pipe takeoff, (8) target veins close to the CS ostium.

How to Implant Cardiac Resynchronization Therapy in a Busy Clinical Practice

Implantation of cardiac resynchronization therapy devices represents one of the more challenging and time-consuming procedures for the clinical electrophysiologist. This article reviews several strategies used to improve efficiency, safety, and effectiveness of cardiac resynchronization therapy implantation. The cornerstone of our strategy to improve efficiency, safety, and quality of cardiac resynchronization therapy implantation is the use of a telescoping guide system with high-quality venography. Competency in subclavian venoplasty and snaring techniques are essential to maintain efficiency and effectiveness during difficult cases.

Simultaneous leadless pacemaker and subcutaneous implantable cardioverter-defibrillator implantation-When vascular options have run out

An end-stage renal failure patient who was planned for a left brachioaxillary arteriovenous graft required an implantable cardioverter-defibrillator for secondary prevention of ventricular tachycardia and a pacemaker for complete heart block but was found to have a right subclavian venous occlusion. Due to the lack of vascular access, we performed a successful subcutaneous implantable cardioverter-defibrillator (S-ICD) and leadless pacemaker implantation. There was no interaction between the devices at the time of implantation, during defibrillation testing and following an appropriate defibrillation therapy.

Venoplasty and Stenting

With expanding indications for cardiac resynchronization therapy and increased survival of patients with cardiovascular disease, the need for lead addition or revision in the presence of an existing implantable electronic device is likely to increase. Partial or complete venous occlusion is frequently encountered and can be a significant barrier to successful procedural outcomes. Percutaneous options, including subclavian venoplasty, can reduce the need for significantly more invasive and morbid procedures and can readily be learned by the implanting physician. Additional invasive techniques, such as coronary sinus venoplasty and stenting, can be useful in cases of difficult left ventricular lead placement.

Venoplasty of a chronic venous occlusion with 'diathermy' for cardiac device lead placement

Venous revascularization is an approach used in patients with total venous occlusion requiring venous access for cardiac device lead placement. Several percutaneous approaches to venous revascularization have been proposed. For the first time, we describe the case of a 69-year-old male with total venous occlusion who was successfully revascularized using a 'diathermy' technique.

Venous Obstruction in Cardiac Rhythm Device Therapy

PURPOSE OF REVIEW

A variety of complex vascular pathologies arise following the implantation of electronic cardiac devices. Pacemaker and defibrillator lead insertion may cause proximal venous obstruction, resulting in symptomatic venous congestion and the compromise of potential future access sites for cardiac rhythm lead management.

RECENT FINDINGS

Various innovative techniques to recanalize the vein and establish alternate venous access have been pioneered over the past few years. A collaborative team of electrophysiologists and vascular specialists strategically integrate the patient's vascular disease into the planning of electrophysiology procedures. When vascular complications occur after device implantation, the same team effectively manages both the resulting vascular sequelae and related cardiac rhythm device challenges. This review will outline the various vascular challenges related to device therapy and offer an effective strategy for their management.

Venous System Interventions for Device Implantation

Subclavian obstruction is common after lead implantation and the need to add or replace a lead is increasing. Subclavian venoplasty (SV) is a safe and effective option for venous occlusion. Peripheral venography overestimates the severity of the obstruction. A wire can usually be advanced into the central circulation for SV. Compared with dilators, SV improves the quality of venous access, providing unrestricted catheter manipulation for His bundle pacing and left ventricular lead implantation. SV preserves venous access and reduces lead burden. SV can easily be added to the implanting physicians lead management options.

Novel experience of laser-assisted 'inside-out' central venous access in a patient with bilateral subclavian vein occlusion requiring pacemaker implantation

Aim

This new laser facilitated 'inside-out' technique was used for transvenous pacemaker insertion in a pacemaker-dependent patient with bilateral subclavian occlusion and a failed epicardial system who is not suitable for a transfemoral approach.

Method and results

Procedure was undertaken under general anaesthesia with venous access obtained from right femoral vein and left axillary vein. 7F multipurpose catheter was used to enter proximal edge of the occluded segment of subclavian vein via femoral approach, which then supported stiff angioplasty wires and microcatheters to tunnel into the body of occlusion. When encountered with impenetrable resistance, 1.4 mm Excimer laser helped delivery of a Pilot 200 wire, which then progressed towards the distal edge of occlusion. Serial balloon dilatations allowed wire tracked into subintimal plane, advanced towards left clavicle using knuckle wire technique, which was then externalized with blunt dissection from infraclavicular pocket area. It was later changed to Amplatz superstiff wire exiting from both ends to form a rail, which ultimately allowed passage of pacing leads after serial balloon dilatation from clavicular end.

Conclusion

Our hybrid 'inside-out' technique permitted transvenous pacemaker insertion without complication and this is, to our knowledge, the first case using laser in this context.

Balloon venoplasty opens the road for an implantable defibrillator patient with complex stenosis

There is an increasing need for physicians to handle venous obstructions in pacemaker/implantable cardioverter-defibrillator implants. Venoplasty performed by an experienced operator is a simple, safe, and fast way to manage this situation and proceed to implant. Compared to other approaches, this strategy may offer particular advantages.

Venoplasty of a chronic venous occlusion allowing for cardiac device lead placement: A team approach

In patients with complete venous occlusion requiring venous access for cardiac device lead placement, venous revascularization is a viable option. A percutaneous approach to venous revascularization has gained popularity. This method reduces patient exposure to more invasive therapies. In this case series, we describe two cases of a total venous occlusion that were successfully revascularized using a “wire externalization” technique. This technique requires the use of antegrade and retrograde access.

Overcoming a subclavian complete occlusion: Simple single lead extraction by the subclavian vein allowing implantation of two new leads and upgrade to CRT-P with multi-site pacing

Central venous obstruction following pacemaker implantation is not uncommon, and can prove challenging in the case of system upgrade. We report a case of DDDR to CRT-P (with multi-site pacing) upgrade, where a subclavian occlusion was overcome resorting to an atrial lead extraction (using only a locking stylet). This allowed regaining of the venous access with subsequent implantation of not just one, but two new leads and subsequent successful upgrade.

A wire transposition technique for recanalization of chronic complex central venous occlusions

PURPOSE

A minimal-invasive interventional technique for recanalization of complex chronic central venous total occlusions is described to overcome difficulties in case of failure of common approaches.

METHOD

We present a patient with a central venous occlusion that caused severe venous congestion of her upper extremity and significant impairment of her forearm hemodialysis shunt. Since the usual transbrachial and transfemoral attempts for recanalization of occluded right subclavian, brachiocephalic, superior vena cava, and proximal internal jugular veins (IJV) failed, the approach was changed to a transjugular access. Only the IJV and subclavian vein occlusions were passed from transjugular.

RESULTS

The key procedure was the switch of a jugular-brachial wire to a femoral-brachial setting. The wire transposition was achieved by snaring the looped stiff end of the jugular-brachial wire outside the jugular sheath from the opposite femoral access.

CONCLUSION

Different approaches should be considered for the recanalization of challenging central venous occlusions. After failed attempts via common access sites, a guidewire transposition maneuver using a combined approach may be particularly helpful for safe and effective endovascular treatment of complex situations.

Balloon venoplasty of subclavian vein and brachiocephalic junction to enable left ventricular lead placement for cardiac resynchronisation therapy

This report describes the successful implantation of a LV lead using balloon venoplasty to overcome a very tight stenosis of the right subclavian vein / brachiocephalic junction for cardiac resynchronisation therapy (CRT-P) in a patient with a right sided CRT-P system and a failed epicardial LV lead. It is important for device implanters to be familiar with interventional equipments and techniques such as balloon venoplasty to overcome difficult venous access.

Endovascular recanalization of central venous access to allow for pacemaker implantation or upgrade

BACKGROUND

Several patients undergoing permanent pacemaker (PPM) implantation/upgrade present with difficult access due to sub- or total central vein occlusion. Our institution has used the endovascular approach to recanalize central veins to allow for subsequent PPM implantation. Here we aim to describe the feasibility and safety of using this approach to allow for PPM implantation/upgrade.

METHODS

From October 2006 to November 2010, 50 consecutive patients who underwent central vein recanalization prior to PPM implantation were included in this analysis.

RESULTS

The population's mean age was 70 years, with a high rate of comorbidities including chronic renal failure (52.0%), congestive heart failure (64.0%), diabetes (33.3%) and peripheral vascular disease (36.0%). The endovascular recanalization procedure was performed via femoral access in all patients; however adjuvant brachial access was required in 13 cases and subclavian vein in one. Subclavian vein (74.5%) followed by innominate vein (21.6%) were the most common locations/target for recanalization. Successful vein recanalization followed by successful PPM implantation/upgrade was achieved in 48 patients (96.0%) without peri-procedural complications. Two patients died during the hospitalization, one due to severe respiratory failure and a second due to complicated end-stage renal disease, although neither was related to the endovascular procedure. No other event, including myocardial infarction, cerebral-vascular accident, bleeding/transfusion, or renal failure was identified.

CONCLUSIONS

This study proved the feasibility and safety of the endovascular approach to recanalize central veins in patients with poor vascular access to allow for further PPM implantation/upgrade.