Cardiovascular implantable electronic devices in hemodialysis patients: an updated review

Severity and Extent of Lead-Related Venous Obstruction in More Than 3000 Patients Undergoing Transvenous Lead Extraction

Background

Lead-related venous stenosis/obstruction (LRVSO) may be a major challenge in patients with cardiac implantable electronic devices (CIED) when device upgrade, insertion of central lines, or creation of an arteriovenous fistula for hemodialysis is indicated. The aim of this study was to evaluate the extent and severity of LRVSO.

Methods

We performed a retrospective analysis of 3002 venograms from patients awaiting transvenous lead extraction (TLE) to assess the occurrence, severity, and extent of LRVSO.

Results

Mild LRVSO occurred in 19.9%, moderate in 20.7%, severe in 19.9% and total venous occlusion in 22.5% of the patients. Moderate/severe stenosis or total occlusion of the subclavian and brachiocephalic veins was found in 38.2% and 22.5% of the patients, respectively. LRSVO was not detected in 16.9% of the patients. Moderate and severe superior vena cava (SVC) obstruction and total SVC occlusion were rare (0.4%, 0.3%, and 0.3%, respectively). Lead insertion on the left side of the chest contributed to an increased risk of LRVSO compared to right-sided implantation. Major thoracic veins on the opposite side may be narrowed in varying degrees.

Conclusion

A total of 60% of the patients with pacemaker or high-voltage leads have an advanced form of LRVSO. Any attempt to insert new pacing leads, central lines, venous ports, or catheters for hemodialysis, or to create dialysis fistula on the same side as the existing lead should be preceded by venography. Furthermore, venography may provide useful information, if it is planned to implant the lead or the catheter on the opposite side of the chest.

Risk Factors for Lead-Related Venous Obstruction: A Study of 2909 Candidates for Lead Extraction

Background: our knowledge of lead-related venous stenosis/occlusion (LRVSO) remains limited and there is still controversy regarding the risk factors for LRVSO. Venography is mandatory before transvenous lead extraction (TLE). Methods: we performed a retrospective analysis of venograms in 2909 patients (39.43% females, average age 66.90 years) who underwent TLE between 2008 and 2021 at high-volume centers. Results: the severity of LRVSO was likely to be dependent on the number of leads in the system (OR = 1.345; p = 0.003), the number of abandoned leads (OR = 1.965; p < 0.001), the presence of coronary sinus leads (OR = 1.184; p = 0.056), male gender (OR = 1.349; p = 0.003) and patient age at first CIED implantation (OR = 1.008; p = 0.021). The presence of permanent atrial fibrillation (OR = 0.666; p < 0.001) and right ventricular diastolic diameter (OR = 0.978; p = 0.006) showed an inverse correlation with the degree of LRVSO. The combined three-model multivariate analysis provided better prediction of LRSVO using the above-mentioned factors than the CHA2DS2-VASc score. Conclusions: the severity of LRVSO is probably dependent on the mechanical impact of the implanted/abandoned leads on the vein wall, therefore the study has demonstrated the central role of system-/procedure-related risk factors. The thrombotic mechanism may be less important, especially long after implantation, and for this reason the combined prediction model for LRVSO in this study was more effective than the CHA2DS2-VASc score.