ICD Leads Extraction and Clearing of Access Way in a Patient With Superior Vena Cava Syndrome: Building A Tunnel

Abstract

Central vein disease is defined as at least 50% narrowing up to total occlusion of central veins of the thorax including superior vena cava, brachiocephalic, subclavian, and internal jugular vein. Thrombosis due to intravascular leads occurs in approximately 30% to 45% of patients early or late after implantation of a pacemaker by transvenous access.In this case, we report a male patient, 65-years old, hypertensive, type 2 diabetic, with atherosclerotic disease, coronary artery disease, underwent coronary artery bypass surgery in the past 10 years, having already experienced an acute myocardial infarction, bearer automatic implantable cardioverter defibrillator for 8 years after an episode of aborted sudden death due to ischemic cardiomyopathy, presenting left superior vena cava syndrome. The use of clopidogrel and rivaroxaban for over a year had no benefit on symptoms improvement.After atrial and ventricular leads extraction, a new shock lead was positioned in the right ventricle using active fixation and a new atrial lead was positioned in the right atrium, passing inside of the stents. Two days after the procedure the patient was asymptomatic and was discharged.

FIGURE 1

Previous automatic implantable cardioverter defibrillator (A), (B), (C), and (D).

FIGURE 2

Leads extraction without (A), (B), (C) and the left subclavian and brachiocephalic veins where they were placed has been partially unobstructed, confirmed after infusion of non-iodinated contrast (D).

FIGURE 3

Angiography of the venous system showing the superior vena cava with an unbridgeable thrombus just above the right atrium (A) and (B). A tip hydrophilic catheter was inserted to overcome the occlusion, with success at this stage of the procedure (C), (D), and (E). The tip hydrophilic catheter was captured by a lassoer catheter inserted into the brachiocephalic vein through the left subclavian vein puncture (F). The guide wire was replaced by a fixed core wire guide (G) and (H).

FIGURE 4

Angioplasty with noncompliant balloon catheter (A) and (B). Implantation of 2 self-expanding stents (C), in the left subclavian vein, brachiocephalic trunk, and the superior vena cava, followed by dilation with balloon catheter (D), and venography (E) and (F), ensuring the access to ICD implantation. A new “mono coil” shock lead was positioned in the apex of the right ventricle (G) and a new atrial lead was positioned in the right atrium (H), passing inside of the stents.