Transvenous Pacemaker Placement: A Review for Emergency Clinicians

BACKGROUND

Transvenous pacemaker placement is an integral component of therapy for severe dysrhythmias and a core skill in emergency medicine.

OBJECTIVE

This narrative review provides a focused evaluation of transvenous pacemaker placement in the emergency department setting.

DISCUSSION

Temporary cardiac pacing can be a life-saving procedure. Indications for pacemaker placement include hemodynamic instability with symptomatic bradycardia secondary to atrioventricular block and sinus node dysfunction; overdrive pacing in unstable tachydysrhythmias, such as torsades de pointes; and failure of transcutaneous pacing. Optimal placement sites include the right internal jugular vein and left subclavian vein. Insertion first includes placement of a central venous catheter. The pacing wire with balloon is then advanced until electromechanical capture is obtained with the pacer in the right ventricle. Ultrasound can be used to guide and confirm lead placement using the subxiphoid or modified subxiphoid approach. The QRS segment will demonstrate ST segment elevation once the pacing wire tip contacts the endocardial wall. If mechanical capture is not achieved with initial placement of the transvenous pacer, the clinician must consider several potential issues and use an approach to evaluating the equipment and correcting any malfunction. Although life-saving in the appropriate patient, complications may occur from central venous access, right heart catheterization, and the pacing wire.

CONCLUSIONS

An understanding of transvenous pacemaker placement is essential for emergency clinicians.

Comparison of the transarterial, transvenous, and superior ophthalmic vein approaches in the treatment of indirect carotid-cavernous fistulas

OBJECTIVE

Indirect carotid-cavernous fistulas (CCFs) are abnormal arteriovenous shunting lesions with a highly variable clinical presentation that depends on the drainage pattern. Based on venous drainage, treatment can be either transarterial (TA) or transvenous (TV). The aim of this study was to compare the outcomes of indirect CCF embolization via the TA, TV, and direct superior ophthalmic vein (SOV) approaches.

METHODS

The authors conducted a retrospective analysis of 74 patients admitted to their institution from 2010 to 2023 with the diagnosis of 77 indirect CCFs as confirmed on digital subtraction angiography.

RESULTS

A total of 74 patients with 77 indirect CCFs were included in this study. Embolization was performed via the TA approach in 4 cases, the TV approach in 50 cases, and the SOV in 23 cases. At the end of the procedure, complete occlusion was achieved in 76 (98.7%) cases. The rate of complete occlusion at the end of the procedure and at last radiological follow-up was significantly higher in the SOV and TV cohorts than in the TA cohort. The rate of recurrence was highest in the TA cohort (25% for TA vs 5.3% for TV vs 0% for SOV, p = 0.68).

CONCLUSIONS

The rate of immediate complete occlusion was higher in the TV and SOV cohorts than in the TA cohort while the rate of complete occlusion at final follow-up was highest in the SOV cohort. The SOV approach was significantly associated with higher rates of postoperative complications. Indirect CCFs require careful examination of the fistulous point and the venous drainage to provide the most effective patient-tailored approach.

Transvenous embolization of noncavernous dural arteriovenous fistulas (dAVFs): A systematic review and meta-analysis

BACKGROUND

Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques.

METHODS

We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications.

RESULTS

From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up.

CONCLUSION

To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.

[Transvenous lead extraction at the University of Szeged: 10-year experience]

Bevezetés: A cardialis implantálható elektromos eszközökhöz kapcsolódó egyes komplikációk időnként részleges vagy teljes rendszereltávolítást, azaz transzvénás elektróda extrakciót igényelnek. A beavatkozások komplexitására és kimenetelére vonatkozó megfigyelések nemzetközi regiszterekből származnak, a kezelt betegcsoportok jellemzői azonban jelentős eltéréseket mutatnak. Célkitűzés: Az intézetünkben 2012 óta szisztematikusan működő extrakciós program eredményeinek összefoglalása és nemzetközi adatokkal való összehasonlítása. Módszerek: Retrospektív módon elemeztük a 2012 és 2022 között extrakcióban részesült betegek klinikai jellemzőit, a beavatkozások indikációit, technikáit és kimenetelét, összevetve ezeket a legnagyobb átfogó európai regiszter (ELECTRa) adataival. Vizsgáltuk továbbá a sikerarányt a „lépcsőzetes eszközbevetés” különböző szintjein. Eredmények: A vizsgálatba 200 beteget (65 ± 14,3 év, 74,5% férfi) vontunk be. Az extrakció indikációja dominálóan infekció volt, melynek aránya jóval meghaladta az ELECTRa-ban közöltet (87,5% vs. 52,8%, p<0,001). Az elektródák implantációs ideje szintén magasabb tendenciát mutatott tanulmányunkban (7,8 ± 6,2 vs. 6,4 ± 5,4 év), továbbá a passzív fixációs elektródák száma is szignifikánsan nagyobbnak bizonyult (62,2% vs. 46,6%, p<0,001). Betegeink egyötöde előzőleg már átesett egy sikertelen extrakciós kísérleten. A beavatkozások alatt nagyobb arányban volt szükség „locking styletek” (81,9% vs. 71,1%, p<0,001) és aktív extrakciós hüvelyek (71,8% vs. 27,1%, p<0,001) használatára. Major komplikáció 4,5%-ban, beavatkozáshoz köthető halál 4 esetben (2%) fordult elő. Procedurális sikert 88,2%-ban értünk el, mely alacsonyabbnak bizonyult az ELECTRa-ban közölt 95,7%-hoz képest. A lépcsőzetes eszközbevetés vizsgálata során a kumulatív klinikai sikerarány 24,8% volt „locki-ng stylettel” végzett húzással, 74,2% a primer aktív hüvellyel, 91,3% magas szintű extrakciós technikákkal (módozatváltás, femoralis extrakció), valamint 96,6%-ban nem sürgősségi szívsebészeti extrakcióval. Megbeszélés és következtetés: A Szegedi Tudományegyetem Elektrofiziológiai Részlegén sikeres, korszerű technikákon alapuló elektróda extrakciós program épült fel az elmúlt 10 évben. A kezelt betegek rizikóstatusa, valamint a beavatkozások komplexitása jóval meghaladja a nemzetközi regiszterek ilyen irányú jellemzőit. Az optimális sikerarány érdekében elengedhetetlen a különböző extrakciós technikák elérhetősége és az azokban való jártasság, valamint az implantálócentrumokkal folytatott szoros oktatási és referálási együttműködés. Orv Hetil. 2023; 164(49): 1954–1964.

Transvenous permanent pacemaker implantation after debranching thoracic endovascular aortic repair; A case series

Debranching thoracic endovascular aortic repair may disturb the implantation of a cardiac implantable electronic device in the anterior thoracic region. In case 1, the bypass graft between the right axillary artery, left axillary artery, and left common carotid artery disturbed pacemaker implantation from the left anterior thoracic region. Therefore, right-sided implantation was selected. By contrast, in case 2, the bypass graft between axillary arteries in the anterior thoracic region was visible on fluoroscopy, and we performed conventional left-sided pacemaker implantation with extra-thoracic puncture. The pacemaker implantations were successful in both cases. The implantation strategies were affected by the number of debranched arteries and visibility of the bypass graft.

Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access

PURPOSE

To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases.

TECHNIQUE

Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle.

CONCLUSION

Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases.

CLINICAL IMPACT

A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.

Case report: A combination of nitroglycerin and adenosine proves effective in repairing a cerebral arteriovenous malformation

Hemorrhage secondary to rupture of a brain arteriovenous malformations (AVM) is one of the initial manifestations, and the main cause of, morbidity and mortality in patients with this condition. Current treatment strategies include endovascular embolization with the goal of AVM obliteration and neurological preservation. In the transvenous endovascular embolization procedure, adenosine is the preferred agent to induce temporary hypotension and allow adequate AVM embolization. We describe the intraoperative management of an adenosine-resistant 38 year-old male who underwent a successful intracranial AVM embolization after concomitant administration of gradually increasing doses of nitroglycerin. This report suggests that nitroglycerin infusion can be combined with adenosine boluses to create a pronounced and dose-dependent hypotension in patients partially unresponsive to adenosine alone.

Transvenous coil embolization of a Cognard V transverse-sigmoid sinus dural arteriovenous fistula

Dural arteriovenous fistulas with drainage into the spinal veins, classified as Cognard type 5, can be challenging to diagnose and treat. Brainstem and cervical spinal cord signal abnormalities on magnetic resonance imaging result from venous congestion, and can mimic tumor, infection, or inflammation.1-3 Transarterial and transvenous embolization techniques can be used to treat dural arteriovenous fistulas endovascularly. Efficacious transvenous treatment relies on the ability to safely catheterize the draining vein at the dural arteriovenous fistula site. Transvenous access options may seem limited in the setting of occluded venous sinuses. This case highlights the technical aspects of the transvenous approach to embolization of a transverse-sigmoid sinus dural arteriovenous fistula within an isolated sinus,4,5 demonstrating traversal of the occluded venous sinus from a contralateral approach.6,7[Media: see text].

Efficacy and safety of endosonography-guided transvascular needle aspiration of thoracic and abdominal lesions: A systematic review and meta-analysis

BACKGROUND

The diagnosis of intrathoracic and abdominal masses is challenging when lesions are located behind major vessels. Endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS)-guided transvascular needle aspiration (TVNA) provides a potentially useful diagnostic tool for such lesions. Data with respect to the safety and outcome of E-TVNA are scarce. Hence, this meta-analysis was conducted to assess the critical role of E-TVNA for diagnosis of various lesions.

METHODS AND MATERIAL

A meta-analysis was performed by pooling the data from studies obtained from comprehensive search of Medline, Embase, and Scopus from January 2000 to September 2022. The outcomes analyzed included sample adequacy, diagnostic accuracy and adverse events including bleeding.

RESULTS

A total of 17 studies (n = 411) were included in the final analysis. The pooled rate of sample adequacy was 91.5% [95% confidence interval (CI): 86.8-96.2], while the pooled rate of diagnostic accuracy was 85.0% (95% CI: 78.9-91.2). The pooled rate of bleeding with E-TVNA was 1.4% (95% CI 0.0-3.1%). All the episodes of bleeding were mild and resolved without any further intervention. There was no significant heterogeneity with respect to various outcomes and results were comparable on sensitivity analysis.

CONCLUSIONS

E-TVNA offers a safe and accurate diagnostic modality for the diagnosis of mediastinal and abdominal lesions located on the other side of major vessels. Selection of potential candidates and close periprocedural observation are essential to improve the outcome.

Transvenous embolization of vein of galen aneurysmal malformations using the "Chapot pressure cooker" technique

METHODS

Two patients, one 5-year-old and one 7-year-old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n-BCA for choroidal VGAMs.

RESULTS

We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform TVE using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils and n-BCA are used to prevent reflux of Onyx.

CONCLUSIONS

In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: (1) without liquid embolic, deployed coils may not occlude the fistula entirely. (2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE.

Combined transarterial and transvenous embolization of multi-hole pial arteriovenous fistula with large varix

BACKGROUND

Pial arteriovenous fistula (AVF) is a vascular fistulous disease in which the cerebral pial artery and vein are directly connected without the intervening nidus within a sub-pial space. Multi-hole pial AVFs, wherein multiple feeders flow into one drainer, are usually formed with complex angioarchitecture and are difficult to treat.

METHODS

A rare case of an adult patient with hereditary hemorrhagic telangiectasia and multi-hole pial AVF was described. A 23-year-old woman was referred to our hospital. She was previously diagnosed with left cerebellar pial AVF with multiple feeders (bilateral superior cerebellar artery and common trunk of the left anterior inferior cerebellar artery and posterior inferior cerebellar) and large varix that had been untreated for 9 years. The enlargement of the large varix with the new second varix formation was revealed by angiography. Although asymptomatic, considered to be a risk for future hemorrhage was the continuous high hemodynamic stress.

RESULTS

Endovascular embolization was performed by securing safe transarterial n-butyl-2-cyanoacrylate injection by transarterial and transvenous coil placement to the shunt points and feeders, resulting in total occlusion of the fistula without any complications. Extensive transvenous coil placement inside the varix allowed safe embolization of the entire fistula with multiple high-flow feeders. Moreover, bidirectional (transarterial and transvenous) retrograde coil embolization enabled firm obliteration of the shunt points.

CONCLUSIONS

Performing combined transarterial and transvenous embolization in a well-balanced manner was considered to treat multi-hole pial AVF to provide a safe and effective embolization.

Transarterial and transvenous pial arteriovenous Fistula embolization: A video case report

Cerebral pial arteriovenous fistulas (pAVFs) are rare and complex high-flow vascular malformations found in pediatric and adolescent populations.1 They are often divided into two groups based on the pattern of venous drainage, galenic or nongalenic. Nongalenic pAVFs are typically supratentorial and carry a high risk of rupture. Their angioarchitecture is very complex with various patterns of feeding arteries and draining veins not originating from dural vessels or the vein of Galen.2 The natural history has not been well established; however, mortality estimates range as high 63%.1 Presentations include hemorrhage, seizure, congestive heart failure, and elevated intracranial pressure.3 We describe the case of an adolescent girl with acute onset of headaches that led to the discovery of an occipital, nongalenic pAVF. Transarterial and transvenous embolizations performed during a single procedure resulted in complete obliteration of the fistula. No complications arose, and the patient remained at her neurological baseline.

Leadless or Conventional Transvenous Ventricular Permanent Pacemakers: A Nationwide Matched Control Study

Background

Leadless ventricular permanent pacemakers (leadless VVI or LPM) were designed to reduce lead‐related complications of conventional VVI pacemakers (CPM). The aim of our study was to assess and compare real‐life clinical outcomes within the first 30 days and during a midterm follow‐up with the 2 techniques.

Methods and Results

This French longitudinal cohort study was based on the national hospitalization database. All adults (age ≥18 years) hospitalized in French hospitals from January 1, 2017 to September 1, 2020, who underwent a first LPM or CPM were included. The study included 40 828 patients with CPM and 1487 with LPM. After propensity score matching 1344 patients with CPM were matched 1:1 with patients treated with LPM. Patients with LPM had a lower rate of all‐cause and cardiovascular death within the 30 days after implantation. During subsequent follow‐up (mean: 8.6±10.5 months), risk of all‐cause death in the unmatched population was significantly higher in the LPM group than in the CPM group, whereas risk of cardiovascular death and of endocarditis was not significantly different. After matching on all baseline characteristics including comorbidities (mean follow‐up 6.2±8.7 months), all‐cause death, cardiovascular death, and infective endocarditis were not statistically different in the 2 groups.

Conclusions

Patients treated with leadless VVI pacemakers had better clinical outcomes in the first month compared with the patients treated with conventional VVI pacing. During a midterm follow‐up, risk of all‐cause death, cardiovascular death, and endocarditis in patients treated with leadless VVI pacemaker was not statistically different after propensity score matching.

Endovascular treatment as the first-line approach for cure of low-grade brain arteriovenous malformation

OBJECTIVE

While microsurgery has been proposed as the first-line treatment for patients with low-grade (Spetzler-Martin grade I or II) brain arteriovenous malformations (bAVMs), recent studies have shown promising results for endovascular treatment (EVT) as a single proper choice for the management of this group of bAVMs. In this study, the authors evaluated the safety and efficacy of EVT as a first-line strategy for curing low-grade bAVMs at their center.

METHODS

All patients with low-grade bAVMs managed primarily by EVT between 2015 and 2021 were enrolled in this study. Patients were evaluated and treated by the same team and followed with the same protocol. The primary endpoint was the efficacy of EVT on the cure of low-grade bAVMs. The second endpoint was the safety of EVT for the treatment of low-grade bAVMs, including procedural complications and long-term clinical outcomes.

RESULTS

A total of 109 patients were enrolled and represented in the study population. The mean patient age was 31.6 ± 14.8 years. Forty-eight AVMs (44%) were Spetzler-Martin grade I and 61 (56%) were grade II. Of 99 patients who completed their EVT sessions, complete exclusion was achieved in 89 patients (89.9%). Overall, complete exclusion was achieved in 59.6% of patients after a single EVT session. At the 6-month follow-up, 106 patients (97.2%) had a favorable outcome. Four patients (4.6%) experienced transient neurological deficits, and 1 patient (0.9%) had a permanent neurological deficit.

CONCLUSIONS

EVT can be offered as the first choice of treatment for select patients with low-grade bAVMs, with a high cure rate and low morbidity.

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

Leadless pacemaker versus transvenous single-chamber pacemaker therapy: peri-procedural aspects, utilization of medical resources and patient acceptance

BACKGROUND

Leadless pacemaker (L-PM) have been developed in order to overcome the lead- and pocket-related complications associated with transvenous pacemaker (T-PM). The impact of L-PM implantation on the utilization of medical resources, patient comfort and therapy acceptance could differ from that of T-PM.

RESEARCH DESIGN AND METHODS

Prospective, single-center study enrolling 243 consecutive patients undergoing PM implantation. Propensity matching for baseline characteristics yielded 77 matched pairs. Procedural data, patient acceptance (assessed by Florida Patient Acceptance Survey, FPAS) and quality of life (QoL) (assessed at the baseline, 1 week, 3 and 6 months) were compared between the two groups (L-PM and T-PM).

RESULTS

The implantation procedure was longer in L-PM than T-PM patients (42.2±16.3 vs. 28.9±11.9 minutes; p<0.001). L-PM was associated with lower intra- and post-operative pain intensity (all p<0.05), shorter hospitalization (3.2±0.5 vs. 3.5±1.1 days; p=0.034), greater patient acceptance (FPAS score: 58.7±7.1 vs. 40.5±4.1; p<0.001), and better QoL on both physical and mental health scales (all p<0.05).

CONCLUSIONS

Although L-PM implantation takes longer than T-PM, it is better tolerated and accepted by patients and is associated with a better QoL.

Neuro-Endovascular Intervention in Traumatic Carotico-Cavernous Fistulae: A Single-Center Experience

Introduction

The aim of this research was to describe a single-center practical experience in the management of traumatic carotid cavernous fistula (CCF).

Methods

There were a total of 31 patients between January 2005 and December 2019 with post-traumatic carotid cavernous sinus fistula (tCCF) who underwent treatment. We classified them into 2 types according to the flow of the CCF: patients with high flow CCF and patients with low flow CCF.

Results

Angiography revealed the high flow types on 21 patients (67.7%), the mean of patients ages are 31.5 years. Onyx embolization was performed in 1 patient (4.76%), transarterial balloon embolization was carried out in 10 patients (47.61%), transarterial coiling in 3 (14.28%) patients while 5 (28.8%) patients underwent transvenous routes to insert the coil and 2 patients (9.52%) were treated conservatively. Complete occlusion was achieved on all patients with coiling whereas the other treatment experiences the reducing flow of the fistula. We obtained 10 patients (32.2%) with a mean of 40.3 years as low flow type CCF. The patients with the low flow type mostly treated conservatively, because their symptoms were acceptable and intermittent.

Conclusion

The ballooning currently became the more affordable treatment in our center. Balloon embolization was recommended for medium- and large-size fistula. The coils should be recommended for small-size fistula. In some cases occlusion of the fistula cannot be obtained using the detachable balloon, a coil can be used to occlude the cavernous sinus via trans arterial or trans venous access. If the fistula failed to be treated in traditional ways using balloons or coils, occlusion of the parent vessels could be another option.

Tortuosity of superior cerebral veins: Comparative magnetic resonance imaging morphometrics in normal subjects and arteriovenous malformation patients

Blood vessel tortuosity results from increased diameter and length in response to higher hemodynamic loads. Tortuosity metrics have not been determined for abnormal superior cerebral veins (SCVs) draining cerebral arteriovenous malformations (AVMs). Draining vein (DV) tortuosity may influence safety and efficacy of retrograde microcatheter navigation during transvenous treatment of pial AVMs. Here, we quantify SCV tortuosity in normal subjects and AVM patients using two image segmentation methods. We used contrast-enhanced brain magnetic resonance (MR) images to define the axis of each SCV through a regularly spaced set of three-dimensional (3D) points defining its skeleton curve. We then calculated two metrics: the "sum of angles metric" (SOAM), which adds all angles of curvature along a vessel and normalizes by vessel length, and the "distance metric" (DM), a tortuosity measure providing a ratio of vessel length to linear distance between vessel endpoints. We analyzed 168 metrics in 43 veins of eight normal subjects and 41 veins of seven AVM patients. In normal subjects, the mean SOAM and DM for SCVs were 21.34 ± 7.49 °/mm and 1.42 ± 0.25, respectively. In AVM patients, DVs had a significantly higher mean SOAM of 30.43 ± 11.38 °/mm (p = .02) and DM of 2.79 ± 1.77 (p = .01) than normal subjects. In AVM patients, DVs were significantly more tortuous than matched contralateral uninvolved SCVs, which were similar in tortuosity to normal subject SCVs. We thus report normative tortuosity metrics of brain SCVs and show that AVM cortical DVs are significantly more tortuous than normal SCVs. Knowledge of these comparative tortuosities is valuable in planning endovenous AVM embolotherapies.

Quality of life of patients undergoing conventional vs leadless pacemaker implantation: A multicenter observational study

BACKGROUND

Leadless pacemakers (L-PM) are an emerging effective and safe technology that offer an alternative to conventional pacemakers (C-PM) for right ventricular stimulation. However, there is little information about their potential benefits for quality of life (QoL) in patients with L-PM. We compared QoL between patients with L-PM and C-PM.

METHODS

The study population comprised patients undergoing single chamber pacemaker implantation from December 2016 to March 2018. The SF-36 questionnaire was used to evaluate QoL at baseline and at 6 months of followup. We also used a questionnaire consisted of 10 specific questions related to the implant procedure.

RESULTS

A total of 106 patients (64 C-PM; 42 L-PM) were included. There were no differences in baseline characteristics between the groups (C-PM vs L-PM), except for age (81.5 vs 77.3 years; P = .012) and diabetes (38% vs 17%; P = .021). Baseline SF-36 scores did not differ between the groups. At 6 months followup, patients in the L-PM group scored significantly higher on physical function (63 vs 42; P < .001), physical role (64 vs 36; P = .004), and mental health (75 vs 65; P = .017), even after adjusting for covariates. Pacemaker-related discomfort and physical restrictions were significantly lower for the L-PM group.

CONCLUSION

L-PM is associated with better QoL than C-PM in both physical and mental health. Patients undergoing L-PM implantation reported less procedure-related discomfort, physical restriction, and preoccupation.

Three-Dimensional Angles of Confluence of Cortical Bridging Veins and the Superior Sagittal Sinus on MR Venography: Does Drainage of Adjacent Brain Arteriovenous Malformations Alter this Spatial Configuration?

Few neuroimaging anatomic studies to date have investigated in detail the point of entry of cortical bridging veins (CBVs) into the superior sagittal sinus (SSS). Although we know that most CBVs join the SSS at an acute angle opposite to the direction of SSS blood flow, the three-dimensional (3-D) spatial configuration of these venous confluences has not been studied previously. This anatomical information would be pertinent to several clinically applicable scenarios, such as in planning intracranial surgical approaches that preserve bridging veins; studying anatomical factors in the pathophysiology of SSS thrombosis; and when planning endovascular microcatheterization of pial veins to retrogradely embolize brain arteriovenous malformations (AVMs). We used the concept of Euclidean planes in 3-D space to calculate the arccosine of these CBV-SSS angles of confluence. To test the hypothesis that pial AVM draining veins may not be any more acutely angled or difficult to microcatheterize at the SSS than for normal CBVs, we measured 70 angles of confluence on magnetic resonance venography images of 11 normal, and nine AVM patients. There was no statistical difference between normal and AVM patients in the CBV-SSS angles projected in 3-D space (56.2° [SD = 22.4°], and 46.2° [SD = 22.3°], respectively; P > 0.05). Hence, participation of CBVs in drainage of pial AVMs should not confer any added difficulty to their microcatheterization across the SSS, when compared to the acute angles found in normal individuals. This has useful implications for potential choices of strategies requiring endovascular transvenous retrograde approaches to treat AVMs. Clin. Anat. 33:293-299, 2020. © 2019 Wiley Periodicals, Inc.

Updates in the management of cranial dural arteriovenous fistula

Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful.

Voltage mapping to guide pacemaker placement in patients with CHD

Transvenous pacemaker implantation for sinus node dysfunction in patients with Fontan palliation presents the difficulty of finding suitable pacing tissue and the potential of causing vascular obstruction in a low-flow circuit. We describe a patient who underwent electro-anatomic voltage mapping to guide a transvenous single chamber lead within her Fontan baffle. This highlights the use of advanced mapping technologies for pacemaker implantation in complex cyanotic heart disease.

The variant with the absence of the superior petrosal venous and sinus: A potential pitfall of transvenous balloon-assisted embolisation of Borden type II transverse-sigmoid dural arteriovenous fistula

We describe a patient with Borden type II transverse-sigmoid dural arteriovenous fistula. On the venous phase of the left vertebral artery injection, there was no superior petrosal veins and sinus on the side of lesion. After transvenous balloon-assisted Onyx embolisation, the patient developed extensive venous infarction from venous occlusion. This report calls attention to a highly unusual variant in which the superior petrosal veins and sinus are absent, and the cerebellar veins will be drained by tributaries of the bridging veins in this circumstance. In such circumstances, occlusion of the bridging vein on the tentorial cerebellar surface may lead to complications during transverse-sigmoid dural arteriovenous fistula embolisation.

Endovascular management of complex superior sagittal sinus dural arteriovenous fistula

Superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVFs) are rare and present unique challenges to treatment. Complex, often bilateral, arterial supply and involvement of large volumes of eloquent cortical venous drainage may necessitate multimodality therapy such as endovascular, microsurgical, and stereotactic radiosurgery techniques. The authors present a complex SSS DAVF associated with an occluded/severely stenotic SSS. The patient underwent a successful endovascular transvenous approach with complete obliteration of the SSS. The authors discuss the management challenges faced on this case.The video can be found here: https://youtu.be/-rztg0_cBXY.

Trans-superior ophthalmic vein approach for treatment of carotid-cavernous fistula

The authors present a case of a patient with a Barrow Type B carotid-cavernous fistula (CCF) who presented with severe symptoms of eye redness, diplopia, and proptosis. Due to the tortuosity and size of her angular vein and the lack of good flow/access via the inferior petrosal sinus, she was treated with a transvenous approach via a large, dilated superior ophthalmic vein for coil embolization of the CCF. The patient had a full angiographic and symptomatic cure. The authors present the treatment plan and strategy and the fluoroscopic recording of the treatment. Nuances of the technique are discussed.The video can be found here: https://youtu.be/ABkGm17-cBU.

Transvenous microguidewire looping technique for breach of ipsilateral inferior petrosal sinus occlusions en route to cavernous sinus dural arteriovenous fistulas

BACKGROUND AND PURPOSE

Transarterial access to dural arteriovenous fistulas (dAVFs) has been popularized by device improvements and novel embolic materials. However, this approach is limited in the cavernous sinus (CS) because of related complications and low cure rates. Although a transvenous approach, via ipsilateral inferior petrosal sinus (IPS), may be more suitable for CS-dAVFs, microcatheter delivery is occasionally impeded by ipsilateral IPS occlusion. Described herein is a microguidewire looping method to breach such occlusions, thus enabling access to CS lesions.

METHODS

A microcatheter is initially advanced into the IPS orifice, and a microguidewire is passed into the occluded IPS. Looping is easily achieved through the resistance met. With greater support of the guiding catheter, the microguidewire (still looped) is then advanced into the CS. When nearing the CS, the microcatheter is further reinforced, and it is navigated along the microguidewire into the CS.

RESULTS

This technique was applied in 10 instances of CS-dAVF with ipsilateral IPS occlusion, enabling ipsilateral access to the CS. In eight cases (80%), microdevice advancement was successful, culminating in effective transvenous coil embolization. Clinical and radiologic outcomes in all patients were excellent, with no delayed post-procedural cranial palsies.

CONCLUSION

This microguidewire looping technique enables safe and effective entry into the CS during transvenous coil embolization of CS-dAVFs with ipsilateral IPS occlusion.

Retrograde leptomeningeal venous approach for dural arteriovenous fistulas at foramen magnum

A 72-year-old man presented with sudden right homonymous hemianopsia. Work-up imaging revealed a left occipital haematoma and an arteriovenous fistula supplied by the meningeal branches to the clivus from the left vertebral artery (VA) with a rostral venous reflux into cortical veins. A microcatheter was advanced through brainstem veins into the venous collector. A compliant balloon was placed in the left VA facing the origin of feeders. The balloon was inflated to protect the vertebrobasilar circulation from embolic migration. Onyx was injected by the transvenous catheter. Control angiogram revealed exclusion of the lesion. Informed consent was obtained from the patient.

A Case of Transvenous Pacemaker Implantation in a 10-year-old Patient

Objective: The aim of this report was to discuss the type, timing, and surgical techniques of permanent pacemaker implantation in a juvenile patient.

Patients: A 17-year-old girl with Down syndrome and congenital heart defects comprised of ventricular septal defects (VSD) and patent ductus arteriosus (PDA) suffered from postoperative complete atrioventricular block (AVB) when she was 7 months old.

Methods and Results: An epicardial pacemaker was implanted just after the occurrence of complete AVB. Due to the pacing threshold of a ventricular lead not being good, the battery showed rapid depletion. Her generator had to be exchanged under general anesthesia every 2–3 years. When she was 10 years old, we implanted a permanent pacemaker transvenously by using cutdown, screw-in and subpectoral pocket techniques. She has shown a satisfactory outcome since then.

Conclusion: Transvenous pacemaker implantation was safe and effective in our young patient without any complications. The timing of surgery and surgical technique are quite important for pacemaker implantation in juvenile patients.

Transvenous closure of large aortopulmonary collateral

Aortopulmonary collaterals (APCs) are occluded either preoperatively or at the time of cardiac surgery in patients with pulmonary atresia and ventricular septal defect (PAVSD). If left untreated, APCs are an important cause of deterioration in the early postoperative period. We present here an unusual case with a large residual APC causing refractory low-output state in the early postoperative period. Usual arterial approach failed due to extensive angulation with ostial narrowing. The large residual APC was successfully closed with an Amplatzer duct occluder (ADO) device delivered through the transvenous route.