Multilevel Venous Obstruction in Patients with Cardiac Implantable Electronic Devices

Abstract

Background and Objectives: The nature of multilevel lead-related venous stenosis/occlusion (MLVSO) and its influence on transvenous lead extraction (TLE) as well as long-term survival remains poorly understood. Materials and Methods: A total of 3002 venograms obtained before a TLE were analyzed to identify the risk factors for MLVSO, as well as the procedure effectiveness and long-term survival. Results: An older patient age at the first system implantation (OR = 1.015; p < 0.001), the number of leads in the heart (OR = 1.556; p < 0.001), the placement of the coronary sinus (CS) lead (OR = 1.270; p = 0.027), leads on both sides of the chest (OR = 7.203; p < 0.001), and a previous device upgrade or downgrade with lead abandonment (OR = 2.298; p < 0.001) were the strongest predictors of MLVSO. Conclusions: The presence of MLVSO predisposes patients with cardiac implantable electronic devices (CIED) to the development of infectious complications. Patients with multiple narrowed veins are likely to undergo longer and more complex procedures with complications, and the rates of clinical and procedural success are lower in this group. Long-term survival after a TLE is similar in patients with MLVSO and those without venous obstruction. MLVSO probably better depicts the severity of global venous obstruction than the degree of vein narrowing at only one point.

Keywords: complications; long-term survival; multilevel lead-related venous obstruction; risk factors; transvenous lead extraction.

Figure 1

Examples of lead-related obstruction of the major thoracic veins. Leads on the left side of the chest. A transesophageal echocardiographic probe can be seen on several images. (A) Severe stenosis isolated to one vein (subclavian). (B) Moderate stenosis affecting two veins (subclavian and brachiocephalic). (C) Three veins affected. Brachiocephalic vein occlusion and severe stenosis of subclavian and superior vena cava veins. (D) Four veins affected. Occlusion of axillary, subclavian, and brachiocephalic veins with severe stenosis of superior vena cava. The extent of collateral circulation through neck (A–D) and thoracic (B,D) veins depends on the degree of obstruction.

Figure 1

Examples of lead-related obstruction of the major thoracic veins. Leads on the left side of the chest. A transesophageal echocardiographic probe can be seen on several images. (A) Severe stenosis isolated to one vein (subclavian). (B) Moderate stenosis affecting two veins (subclavian and brachiocephalic). (C) Three veins affected. Brachiocephalic vein occlusion and severe stenosis of subclavian and superior vena cava veins. (D) Four veins affected. Occlusion of axillary, subclavian, and brachiocephalic veins with severe stenosis of superior vena cava. The extent of collateral circulation through neck (A–D) and thoracic (B,D) veins depends on the degree of obstruction.

Figure 2

Examples of lead-related obstruction of the major thoracic veins. Leads on the left side of the chest. A transesophageal echocardiographic probe can be seen. (A) Severe stenosis isolated to one vein (brachiocephalic). (B) Two veins affected. Occlusion of subclavian and brachiocephalic veins. (C) Three veins affected. Stenosis of subclavian vein, occlusion of brachiocephalic vein, and severe stenosis of superior vena cava. (D) Four veins affected. Occlusion of axillary, subclavian, and brachiocephalic veins, and severe stenosis of superior vena cava. Well-developed collateral circulation through neck and thoracic (B–D) veins.

Figure 3

Six examples of lead-related obstruction of the major thoracic veins in patients with leads on the right side of the chest. A transesophageal echocardiographic probe can be seen. (A,B) Moderate stenosis isolated to one vein (right brachiocephalic vein). (C,D) Two veins with severe stenosis (right subclavian and right brachiocephalic veins). (E,F) Three veins affected. Severe stenosis of right subclavian and brachiocephalic veins and severe stenosis of superior vena cava. Collateral circulation through neck (A,D,F) and thoracic (E,F) veins.

Figure 4

Relationship between the severity of maximal vein stenosis and the number of affected leads (with borderline or more severe venous stenosis/occlusion); Spearman “r” correlations = 0.870. p < 0.001, and number of leads = 0.7135^{(0.2839 × x)}.