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

Abstract

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.

Keywords: Extraction; Implantable cardioverter–defibrillator; Permanent pacemaker; Simultaneous traction; Snaring; Venous occlusion.

Figure 1

Left: Simultaneous countertraction (“body flossing”) for venous stenosis. A: Peripheral venography showing a subclavian vein subtotal occlusion. B: Buckling of sheath as it will not track over the wire through the stenosis. C: Snaring of the distal end of the wire in the inferior vena cava. D: Sheath passes the stenotic region during simultaneous countertraction on the wire. E: Final system showing a new left ventricular lead. Right: Simultaneous countertraction (body flossing) for venous tortuosity. F: Peripheral venography showing innominate vein tortuosity. G: Buckling of sheath as it will not track over the wire through the tortuosity. H: Snaring of the distal end of the wire in the right atrium. I: Sheath passes the tortuous region during simultaneous countertraction on the wire. J: Final system showing a new right atrial lead.