Fistula from right internal mammary artery to superior vena cava after use of a laser sheath to extract a pacemaker lead

Abstract

A 55-year-old woman presented with dyspnea on exertion due to a right internal mammary artery-to-superior vena cava arteriovenous fistula that occurred after pacemaker lead extraction with a laser sheath. The fistula was successfully repaired by placing a covered stent in the right internal mammary artery. In this unusual location, endovascular stenting is a reasonable alternative to coil embolization or surgical repair of an arteriovenous fistula resulting from laser lead extraction.

Keywords: Arteriovenous fistula/etiology/therapy; blood vessel prosthesis/implantation; defibrillators, implantable; device removal/adverse effects/methods; electrodes, implanted; iatrogenic disease; laser therapy; lasers, excimer/adverse effects; mammary artery, right internal; pacemaker, artificial; stent-graft; vena cava, superior.

Fig. 1 Before lead extraction, chest radiographs in A) the posteroanterior projection and B) the lateral projection show the permanent pacemaker–implantable cardioverter-defibrillator in a low left pectoral position, along with its 2 leads. Two additional, nonfunctional leads are present from a previous right-sided device.

Fig. 2 Selective angiography of the right internal mammary artery (right anterior oblique projection) shows a large arteriovenous fistula filling the superior vena cava. To close the fistula, we engaged the right internal mammary artery with an 8F hockey-stick guiding catheter, which was inserted percutaneously through the right femoral artery. 1 = 8F internal mammary artery guiding catheter; 2 = proximal right internal mammary artery; 3 = arteriovenous fistula; 4 = superior vena cava

Fig. 3 Angiography shows the 5 × 16-mm covered stent positioned across the fistula before deployment.

Fig. 4 After placement of the stent-graft, repeat selective angiography of the right internal mammary artery (right anterior oblique projection) shows that the arteriovenous fistula is totally sealed. 1 = proximal right subclavian artery; 2 = proximal right internal mammary artery without evidence of a fistula