Treatment of superior vena cava obstruction secondary to pacemaker wires with balloon venoplasty and insertion of metallic stents

Balloon venoplasty for disdialysis syndrome due to pacemaker-related superior vena cava syndrome with chylothorax post-bacteraemia: A case report

BACKGROUND

Although superior vena cava (SVC) syndrome has also been reported as a late complication of pacemaker (PM) implantation, acute onset of SVC syndrome caused by disdialysis syndrome in patients with PM implantation is very rare. There are no specific therapies or guidelines.

CASE SUMMARY

A 96-year-old woman receiving dialysis was implanted with a PM due to sick sinus syndrome. She was referred to our facility for chest discomfort experienced during dialysis. Upon examination, unilateral pleural effusion on the right side was cloudy with a foul odour. The patient was diagnosed with pyothorax and treated with antibiotics. After the effusion was reduced, it gradually reaggravated and remained cloudy. In this case, SVC syndrome, which is generally considered a late complication after PM implantation, rapidly developed following the bacteraemia, resulting in impaired venous return, chylothorax, and disdialysis syndrome. After catheter intervention for SVC stenosis, the patient's symptoms promptly improved. The patient has been recurrence-free for a year.

CONCLUSION

Acute SVC syndrome can cause dysdialysis in PM-implanted patients. Catheter intervention alone has improved this condition for a traceable period.

Insights Into Endovascular Management of Superior Vena Cava Obstructions

Superior vena cava obstruction results from any limitation of blood flow through the superior vena cava. Circulation to the heart may persist through various collateral vessels whose development depends on the level of obstruction. Depending on the level and degree of occlusive disease, the severity of clinical symptoms may vary considerably, up to lethal. Etiologies have changed dramatically in recent years, mainly due to the increasing use of intravascular devices. However, guidelines for treatment are lacking, and various options are available. Endovascular therapies developed considerably in recent years, may offer a rapid improvement in symptoms and proved to be safe. However, knowledge and selection of appropriate techniques are essential to venous angioplasty, involving specific tools to guarantee satisfying outcomes. This review aims to discuss the particular venous anatomy of the upper body, the physiopathology of superior vena cava obstruction, and specificities of endovascular treatment compared with other management options.

Superior vena cava syndrome after pacemaker implantation treated with direct oral anticoagulation

Background

Superior Vena Cava (SVC) syndrome, is a quite rare but serious complication after pacemaker lead implantation; most patients are asymptomatic due to the development of adequate venous collateral circulation.

Case presentation

We report a case of a 75-year-old woman who developed SVC syndrome after transvenous pacemaker implantation with complete resolution of the thrombosis after 3 months of oral anticoagulation.

Conclusions

Generally other causes as malignancy are considered to be the most common etiology of SVC syndrome, but benign iatrogenic causes, mainly intravascular devices (central vein catheters, cardiac defibrillators and pacemaker wires), are becoming increasingly common. Procedures performed on venous vasculature, causing a possible intimal injury or vein stenosis, provoked by transvenous leads, seem to be the most reasonable explanation for the observed complication.

Central Venoplasty in Patients with Cardiac Implantable Electronic Devices

Objective The aim of this study was to assess the safety and effectiveness of the central venous angioplasty in patients with central venous occlusion and cardiac implantable electronic device (CIED) without lead extraction.

Materials and Methods A retrospective study was used to evaluate the effectiveness of 37 central venous angioplasty procedure for 15 patients with CIED without lead extraction.

Results Technical success was achieved in 97% (n = 36/37) and clinical success was achieved in 89% (33/37) of the procedures. One procedure failed recanalization of chronic total occlusion of the left subclavian vein, and the patient required fistula embolization due to severe arm swelling. Another procedure failed initially to recanalize long-segment occlusion involving the right subclavian vein/brachiocephalic vein and superior vena cava in a patient with a history of Hickman line and left-sided CIED. This was successfully recanalized and angioplastied on a subsequent session. No lead fracture or dislodgment was documented in any procedure. No procedure-related complication was documented within 2 weeks after the angioplasty. Six-month primary patency was achieved in 62% (23/37) of the procedures. Ten patients (66%) required an average of 1.4 reinterventions (range: 1–4 interventions) during the follow-up time with mean time to reintervention of 318 days (5–1,380 days). Two patients required early reinterventions within 10 days due to catheter dysfunction.

Conclusion Findings of this study support the existing evidence on the safety and effectiveness of balloon angioplasty without lead extraction.

Lead-related superior vena cava syndrome: Management and outcomes

BACKGROUND

Superior vena cava (SVC) syndrome includes the clinical sequalae of facial and bilateral upper extremity edema, dizziness, and occasional syncope. Historically, most cases have been associated with malignancy and treatment is palliative. However, cardiac device leads have been identified as important nonmalignant causes of this syndrome. There are little data on the effectiveness of venoplasty and lead extraction in the management of these patients.

OBJECTIVE

The objective of this study was to report the findings associated with the use of balloon angioplasty and lead extraction in the management of 17 patients with lead induced SVC syndrome.

METHODS

Data collected from January 2003 to July 2019 identified 17 cases of SVC syndrome at our tertiary center. Their outcomes were compared to a control group of patients without SVC syndrome. A P value of <.05 was considered statistically significant.

RESULTS

Of the 17 patients, 13 (76%) underwent transvenous lead extraction and venoplasty. Three patients (18%) were treated with venoplasty alone, and 1 patient (6%) underwent surgical SVC reconstruction. In 10 patients (59%), transvenous reimplantation was necessary. Symptom resolution was achieved in all 17 patients and confirmed at both 6 and 12 months' follow-up. There was no significant difference in the rate of complications associated with transvenous lead extraction for SVC syndrome vs control.

CONCLUSION

In patients with SVC syndrome, venoplasty and lead extraction are safe and effective for resolution of symptoms and maintaining SVC patency.

Venous Obstruction in Cardiac Rhythm Device Therapy

PURPOSE OF REVIEW

A variety of complex vascular pathologies arise following the implantation of electronic cardiac devices. Pacemaker and defibrillator lead insertion may cause proximal venous obstruction, resulting in symptomatic venous congestion and the compromise of potential future access sites for cardiac rhythm lead management.

RECENT FINDINGS

Various innovative techniques to recanalize the vein and establish alternate venous access have been pioneered over the past few years. A collaborative team of electrophysiologists and vascular specialists strategically integrate the patient's vascular disease into the planning of electrophysiology procedures. When vascular complications occur after device implantation, the same team effectively manages both the resulting vascular sequelae and related cardiac rhythm device challenges. This review will outline the various vascular challenges related to device therapy and offer an effective strategy for their management.

Preoperative management of arteriovenous fistula (AVF) for hemodialysis

Native arteriovenous fistula (AVF) is the favorite access for hemodialysis (HD). The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommends its creation in most patients with renal failure. Unfortunately, intensive efforts to promote native AVF in patients with marginal vessels have increased the rate of primary fistula failure. A non-functioning fistula prompts the use of central venous catheter (CVC) that, unlike AVF, has been associated with an increased risk of morbidity and mortality among patients receiving HD. We believe that successful and timely AVF placement relies on the development of a multidisciplinary integrated preoperative program divided into five stages: (i) management of patients with advanced chronic kidney disease (CKD), (ii) management of preoperative risk factors for AVF failure, (iii) planning of native AVF, (iv) assessment of patient eligibility and (v) preoperative vascular mapping. Focusing specifically on native AVF, we review scientific evidence regarding preoperative management of this vascular access in order to favor construction of long-term functioning fistula minimizing development of severe complications.

Endovascular Treatment of Superior Vena Cava Syndrome via Balloon-in-Balloon Catheter Technique with a Palmaz Stent

Superior vena cava syndrome is a well-known disease entity that carries substantial rates of morbidity and mortality. Although most cases of superior vena cava syndrome are secondary to a malignant process, additional causes (such as mediastinal fibrosis, pacemaker lead implantation, or central venous catheter placement) have been reported. Multiple treatment options include percutaneous transluminal angioplasty, stent implantation, thrombolysis, mechanical thrombectomy, and venous grafting. We present a case of superior vena cava syndrome in a symptomatic 30-year-old woman who obtained complete relief of obstruction and marked symptomatic improvement through venoplasty and stenting, aided by our use of a balloon-in-balloon catheter system.

Superior Vena Cava Rupture Caused During Balloon Dilation for Treatment of SVC Syndrome Due to Repetitive Catheter Ablation

A 29-year-old woman with an implanted AAI mode permanent pacemaker, who had undergone catheter ablation for inappropriate sinus tachycardia 4 times, experienced complications of superior vena cava (SVC) syndrome. Severe stenosis of the SVC wall was observed in computed tomograms. During balloon dilation for the treatment of SVC syndrome, the SVC was ruptured, resulting in cardiac tamponade. An emergency operation was performed using percutaneous cardiopulmonary support (PCPS). A longitudinal tear 1 cm in length was identified at the junction of the right atrium and the SVC, requiring a patch plasty using an autologous pericardium 2.5 cm x 3 cm in size.

SVC rupture is a complication to be completely avoided when we perform balloon dilation for the treatment of SVC syndrome. Therefore, the indication of balloon dilation for the treatment of SVC syndrome requires critical examination and attention.

Treatment of pacemaker-induced superior vena cava syndrome by balloon angioplasty and stenting

Superior vena cava (SVC) syndrome is a rare but serious complication after pacemaker implantation. This report describes three cases of SVC syndrome treated with venoplasty and venous stenting, with an average follow-up of 30.7 (±3.1) months. These cases illustrate that the definitive diagnosis, and the extent and location of venous obstruction, can only be determined by venography.

Percutaneous Transvenous Angioplasty of Left Innominate Vein Stenosis Following Right Side Permanent Pacemaker Implantation- A Left Femoral Vein to Left Axillary Vein Approach

Central venous stenosis after the insertion of a permanent pacemaker is a well recognized complication. This late complication is encountered when there is a need to change the pacemaker lead or extract it. We describe a young male who had such a complication after many years after right side pacemaker implantation. The lesion was managed percutaneously leading to placement of a new lead from the left side.

Patency rates for angioplasty in the treatment of pacemaker-induced central venous stenosis in hemodialysis patients: results of a multi-center study

While hemodialysis access ligation has been used to manage pacemaker (PM) and implantable cardioverter-defibrillator (ICD) lead-induced central venous stenosis (CVS), percutaneous transluminal balloon angioplasty (PTA) has also been employed to manage this complication. The advantages of PTA include minimal invasiveness and preservation of arteriovenous access for hemodialysis therapy. In this multi-center study we report the patency rates for PTA to manage lead-induced CVS. Consecutive PM/ICD chronic hemodialysis patients with an arteriovenous access referred for signs and symptoms of CVS due to lead-induced CVS were included in this analysis. PTA was performed using the standard technique. Technical and clinical success was examined. Technical success was defined as the ability to successfully perform the procedure. Clinical success was defined as the ability to achieve amelioration of the signs and symptoms of CVS. Both primary and secondary patency rates were also analyzed. Twenty-eight consecutive patients underwent PTA procedure. Technical success was 95%. Postprocedure clinical success was achieved in 100% of the cases where the procedure was successful. The primary patency rates were 18% and 9% at 6 and 12 months, respectively. The secondary patency rates were 95%, 86%, and 73% at 6, 12, and 24 months, respectively. On average, 2.1 procedures/year were required to maintain secondary patency. There were no procedure-related complications. This study finds PTA to be a viable option in the management of PM/ICD lead-induced CVS. Additional studies with appropriate design and sample size are required to conclusively establish the role of PTA in the management of this problem.

Stabilization of the Coronary Sinus Electrode Position with Coronary Stent Implantation to Prevent and Treat Dislocation

INTRODUCTION

Coronary sinus (CS) leads used for cardiac resynchronization have undergone development in the last years. However, dislocation rate remained high (5-9%). The aim of this study was to investigate the effectiveness and safety of stent implantation in a CS side vein to stabilize the left ventricular lead position after postoperative or intraoperative dislocation of the electrode.

METHODS AND RESULTS

Thirty-six patients (age: 64 +/- 9.7 years, 19 primary, 17 ischemic cardiomyopathy, NYHA class III: 30, IV: 6) were treated with stenting. The procedure was performed because of postoperative dislocation in seven patients, while dislocation was observed during the implantation in 29 cases. The electrode was repositioned into the desired position and a bare metal coronary stent was introduced via another guide wire. The stent was deposited at 5- to 15-mm proximal to the tip of the electrode with a pressure of 6 to 14 atmospheres. Control angiography showed no blood flow compromise in any of the side branches or in the coronary sinus. Control echocardiography did not show pericardial effusion due to stenting. During follow-up (11.5 +/- 5.5, 2-23 months), left ventricular pacing threshold increased from 2.2 to 5.6 V in one patient, but dislocation was not found by fluoroscopy. Clinically important pacing threshold increase was not detected in the other cases. Impedance measurements did not suggest lead insulation failure.

CONCLUSION

Stent implantation to stabilize the left ventricular lead position seems to be a useful and safe procedure in the treatment of patients with complicated coronary sinus anatomy or lead instability.

Superior Vena Cava Rupture during Balloon Angioplasty and Stent Placement to Relieve Superior Vena Cava Syndrome: A Case Report

Percutaneous stenting of the superior vena cava (SVC) has been an accepted therapy for SVC syndrome for more than a decade. Complications are uncommon and usually of minor consequence. Three previous reports have described ruptures of the SVC during venoplasty with death on one occasion. We report a fourth case of SVC rupture during angioplasty and stenting that required immediate pericardiocentesis followed by open surgical repair via sternotomy for direct control and repair. An algorithm for rapid recognition and prompt intervention is described.

Percutaneous treatment of the superior vena cava syndrome via an excimer laser sheath in a patient with a single chamber atrial pacemaker

A 21-year-old woman presented with a pacemaker-associated superior vena cava (SVC) syndrome refractory to medical therapy. In the past, treatment of this condition has involved surgical exploration which is invasive. With the evolution of percutaneous techniques, treatment has included venoplasty and stenting over the pacemaker lead. There is limited experience with a more advanced percutaneous technique in which the lead is extracted by an excimer laser sheath. The extraction is immediately followed by venoplasty and stenting at the site of stenosis with subsequent implantation of a new permanent pacemaker at the previously occluded access site. The patient underwent this procedure which proved to be safe, minimally invasive, and an efficient method of treating SVC syndrome secondary to a single chamber atrial pacemaker.

Placement of Transvenous Pacemaker and ICD Leads Across Total Chronic Occlusions

OBJECTIVE

To establish a method of implantation for device leads across total venous occlusions.

BACKGROUND

Indications for pacemaker and implantable cardiac defibrillator implantation continue to expand. Chronic venous occlusions are increasingly encountered with lead placement. Some degree of obstruction can be as high as 13% before device implantation and 50% after transvenous device implantation. We report an approach of venoplasty/dilatation of chronic total occlusions to allow lead placement.

METHODS

From January 1, 2002 through December 16, 2004, 1,356 systems (initial and upgrade) were implanted at the University of Virginia. At the time of device implant, seven patients were noted to have chronic venous occlusions and alternative access was precluded. Four of the seven patients had an existing system; the other three received initial implantations. Subsequently, these seven patients had a 5 Fr catheter placed in the basilic/axillary/subclavian vein and a venogram was obtained to demonstrate the area of chronic occlusion. A guide wire was advanced across the lesion for initial recanalization. Dilatation or venoplasty was performed at the occluded site. A guide wire was retained across the lesion and the patient underwent lead implantation.

RESULTS

In all seven patients, recanalization was achieved and leads were successfully placed. There were no complications or damage to the vessels or existing leads.

CONCLUSIONS

Venoplasty or dilatation of chronic total venous occlusion is a safe and effective technique, which allows for placement of transvenous leads.

Thrombolytic therapy with tissue plasminogen activator for superior vena cava thrombosis in an infant with sepsis

Superior vena cava syndrome is rare in infants, and rarely responds to conservative treatment. We report a 22-mo-old girl with superior vena cava syndrome due to the use of a central venous line and/or sepsis. Doppler study and computed tomography angiography of the neck showed thrombosis within the superior vena cava and jugular veins. She was admitted to a monitored setting and received recombinant tissue plasminogen activator for 2 d. The clinical features of superior vena cava syndrome disappeared completely 3 d after treatment. No complications were observed and radiological investigations showed blood flow through the thrombus after treatment. Systemic recombinant tissue plasminogen activator may be useful in the treatment of superior vena cava syndrome in children.

Interventions in leaks and obstructions of the interatrial baffle late after Mustard and Senning correction for transposition of the great arteries

The objective of this study was to describe the institutional experience with interventional treatment of atrial sequelae late after atrial correction for transposition of the great arteries (TGA). A retrospective observational study identified 13 long-term survivors of atrial correction for TGA (median age, 20.5 years; range, 13.8-33.0) with atrial inflow obstruction and/or interatrial defects. Balloon-expandable stents were used for relief of atrial inflow obstructions and interatrial defects closed with devices. Feasibility, periprocedural complications, residual or new obstructions or leaks at follow-up were investigated. Fourteen successful procedures were performed in 12 patients; one procedure failed. Five stents were placed for obstruction of the superior caval vein, three for obstruction of the inferior caval vein, and one for obstruction of the pulmonary venous return. Five septal occluders were implanted. Localization of the interatrial defects required atypical implantation techniques and resulted in atypical device positions. No complications occurred with stent or device implantation. There were no residual shunts through or around the septal occluders. None of the patients had new implant-related obstruction or leakage during a median follow-up of 21 months (range, 6-45). Stent implantation for obstruction of the pulmonary or systemic venous return in patients after atrial redirection for TGA is safe and effective. Follow-up suggests excellent maintenance of patency. Interatrial defects can be closed with septal occluders despite atypical defect positions in these patients. Combined use of both devices in adjacent positions is feasible. These interventions help to avoid high-risk surgery.

Indications and techniques of pediatric cardiac pacing

There are special challenges associated with the use of transvenous pacemakers in children. For example, a child's chest cavity or vascular dimensions could be too small to host the generator and leads available or required. If leads are implanted, they may stretch as the child grows. This increases the risk that the leads will later dislodge or fracture. Moreover, children requiring pacemakers often have coexisting congenital heart defects and the structural abnormalities of those could hinder easy placement of the pacing system. This article will first review the indications for permanent pacing in children and will then describe the unique challenges associated with such use.