Proposed strategies to overcome venous occlusion in the implantation of a cardiac implantable electronic device: A case report and literature review

Abstract

This case report describes a successful balloon venoplasty to overcome a total occlusion from the brachiocephalic vein to the superior vena cava in a patient undergoing cardiac resynchronization therapy. It is crucial for implanting physicians to be familiar with strategies to overcome venous occlusion in lead implantation, especially balloon venoplasty, which is an effective and safe approach.

Keywords: balloon venoplasty; cardiac implantable electronic device; cardiac synchronization therapy; pacemaker; venous occlusion.

Figure 1

(A) Venography via the left upper arm demonstrated total occlusion from the brachiocephalic vein (white arrow) to the superior vena cava (SVC) (arrowhead) with abundant collaterals. Left subclavian vein (♦). (B) TERUMO GLIDEWIRE^® (▴) with support of a Mustang balloon (3.0 × 40 mm) failed to cross the junction of the brachiocephalic vein and SVC. (C) TERUMO GLIDEWIRE^® (⋆) with the support of a multipurpose catheter was advanced to the left internal jugular vein. The antegrade Hi-Torque Connect™ guidewire was successfully advanced to the inferior vena cava. (D) A Mustang balloon (12.0 × 80 mm) was used to dilate the SVC and brachiocephalic vein with 6 atm.

Figure 2

(A) The angiogram showed a patent brachiocephalic vein and superior vena cava after balloon venoplasty. (B) Implantation of right atrial, right ventricular and left ventricular leads.

Figure 3

(A) Treatment algorithm in patients with a preexisting CIED. *In the setting of the pre-existing VVI mode with lead failure. §According to the Heart Rhythm Society expert consensus statement (9), the indications are as follows. Class I: Lead infection, thromboembolic events related to thrombus on the lead, SVC stenosis or occlusion preventing implantation of a necessary lead, planned stent deployment in a vein containing a lead, life-threatening arrhythmias secondary to retained leads. Class IIa: Severe chronic pain at the device or lead insertion site, CIED location interfering with the treatment of malignancy, if CIED implantation would require more than 4 leads on one side or more than 5 leads through the SVC, an abandoned lead interfering with the operation of a CIED system. In patients with lead infection, a new lead can be reimplanted after a complete antibiotic course. The duration depends on the type of infection and is described in the HRS expert consensus. ^¥Extraction of lead as a first-line approach to lead revision or device upgrade for patients with venous occlusion can be useful in experienced centers, and the priority depends on the operator's discretion and expertise (9). ^†If the vascular recoil would hinder the lead implantation or patients present with SVC syndrome, venoplasty with subsequent stenting is needed (9). (B) Treatment algorithm in patients without preexisting CIED. *Indications for VVI: fixed atrial tachyarrhythmia with symptomatic bradycardia; Severe pacemaker syndrome occurred in nearly 20% of VVIR-paced patients, and the baseline predictors for pacemaker syndrome are lower sinus rate and higher programmed pacemaker rate (21).