Symptomatic deep venous thrombosis of the arm associated with permanent transvenous pacing electrodes

Upper Extremity Deep Vein Thrombosis and Asymptomatic Vein Occlusion in Patients With Transvenous Leads: A Systematic Review and Meta-Analysis

Aims: The presence of transvenous leads for cardiac device therapy may increase the risk of venous thromboembolisms. The epidemiology of these complications has not yet been determined systematically. Therefore, this study aims to determine (I) the incidence of symptomatic upper extremity deep vein thrombosis (UEDVT) and (II) the prevalence of asymptomatic upper extremity vein occlusion in patients with transvenous leads, both after the initial 2 months following lead implantation.

Methods: PubMed, EMBASE, and Cochrane Library were searched until March 31, 2020 to identify studies reporting incidence of UEDVT and prevalence of asymptomatic vein occlusion after the initial 2 months after implantation in adult patients with transvenous leads. Incidence per 100 patient years of follow-up (PY) and proportions (%) were calculated to derive pooled estimates of incidence and prevalence.

Results: Search and selection yielded 20 and 24 studies reporting on UEDVT and asymptomatic vein occlusion, respectively. The overall pooled incidence of UEDVT was 0.9 (95% CI 0.5–1.4) per 100PY after 2 months after lead implantation. High statistical heterogeneity was present among studies (I² = 82.4%; P = < 0.001) and only three studies considered to be at low risk of bias. The overall pooled prevalence of asymptomatic upper extremity vein occlusion was 8.6% (95% CI 6.0–11.5) with high heterogeneity (I² = 81.4%; P = <0.001). Meta-regression analysis showed more leads to be associated with a higher risk of UEDVT.

Conclusion: Transvenous leads are an important risk factor for symptomatic UEDVT, which may occur up to multiple years after initial lead implantation. Existing data on UEDVT after lead implantation is mostly of poor quality, which emphasizes the need for high quality prospective research. Asymptomatic vein occlusion is present in a substantial proportion of patients and may complicate any future lead addition.

Clinical Trial Registration: (URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178136, Identifier: PROSPERO 2020 CRD42020178136).

Deep Venous Thrombosis of the Upper Limbs

Deep venous thrombosis of the upper limbs is rare and represents less than 2-3% of all cases of deep venous thrombosis. Reviewing our series of 25 patients we decided that follow-up and symptomatic treatment produce acceptable results, since the disease has a benign natural history. Fibrinolytic agents administered under strict limitations (The Consensus Conference 1980, Ann Int Med) are efficient in early cases, but its ability to change the natural course of the disease has not been proved. Surgical approach should be reserved for cases with secondary ischaemia and/or a resectable extraluminal mass.

Laser lead extraction to facilitate cardiac implantable electronic device upgrade and revision in the presence of central venous obstruction

Aims

The number of procedures involving upgrade or revision of cardiac implantable electronic devices (CIEDs) is increasing and the risks of adding additional leads are significant. Central venous occlusion in patients with pre-existing devices is often asymptomatic and optimal management of such patients in need of device revision/upgrade is not clear. We sought to assess our use of laser lead extraction in overcoming venous obstruction.

Methods and results

Patients in need of device upgrade/revision underwent pre-procedure venography to assess venous patency. In patients with venous occlusion or stenosis severe enough to preclude passage of a hydrophilic guide wire, laser lead extraction with retention of the outer sheath in the vasculature was performed with the aim of maintaining a patent channel through which new leads could be implanted. Data were recorded on a dedicated database and patient outcomes were assessed. Between July 2004 and April 2012, laser lead extractions were performed in 71 patients scheduled for device upgrade/revision who had occluded or functionally obstructed venous anatomy. New leads were successfully implanted across the obstruction in 67 (94%) cases. There were two major complications (infection) and four minor complications with no peri-procedural mortality. Device follow-up was satisfactory in 65 (92%) cases with mean follow-up up to 26 ± 19 months.

Conclusion

Laser lead extraction is a safe and effective option when managing patients with central venous obstruction in need of CIED revision or upgrade.

Predictors of venous obstruction following pacemaker or implantable cardioverter-defibrillator implantation: a contrast venographic study on 100 patients admitted for generator change, lead revision, or device upgrade

AIM

Venous obstruction following transvenous device implantation rarely cause immediate clinical problems. When lead revision or device upgrade is indicated, venous obstruction become a significant challenge. The aim of this study was to determine the predictors of venous obstruction after transvenous device implantation, and to asess likely effects of antiplatelet/anticoagulant drugs in preventing venous thrombosis.

METHODS AND RESULTS

Between March 2005 and July 2006, contrast venography was performed in 100 patients who were candidates for generator change, lead revision, or device upgrade. Vessel patency was graded as either completely obstructed, partially obstructed (>70%), or patent. The incidence of venous obstruction was 26%, with 9% of patients having total obstruction and 17% of patients exhibiting partial obstruction. No statistically significant differences between obstructed and non-obstructed patients were seen for age, sex, indication for device implantation, atrial fibrillation, cardiothoracic ratio, insulation material, operative technique, device type, and manufacturer (all Ps > 0.05). In a univariate analysis, multiple leads (P = 0.033), and presence of dilated cardiomyopathy (P = 0.036) were associated with higher risk of venous obstruction, whereas anticoagulant/antiplatelet therapy (P = 0.047) significantly reduced incidence of venous obstruction. Multivariate logistic regression analysis showed that only number of the leads (P = 0.039, OR: 2.22, and 95% CI: 1.03-4.76) and antiplatelet/anticoagulant therapy (P = 0.044, OR: 2.79, and 95% CI: 0.98-7.96) were predictors of venous obstruction.

CONCLUSION

Total or partial obstruction of the access veins occurs relatively frequently after pacemaker or ICD implantation. Multiple pacing or ICD leads are associated with an increased risk of venous obstruction, whereas antiplatelet/anticoagulant therapy appears to have a preventive effect on development of access vein thrombosis.

Comparative thrombogenicity of pacemaker leads

To evaluate the thrombogenicity of transvenous silicone and polyurethane pacemaker leads, 9 of 12 anesthetized Yorkshire pigs (27-32 kg) were implanted with silicone (n = 5) or polyurethane (n = 4) pacemaker leads via a femoral vein. The remaining three pigs served as controls. All 12 pigs were injected with autologous indium-111 labeled platelets (300-420 muCi) 24 hours before anesthesia induction. The pigs were monitored for 3 hours under a gamma camera. Radioactivity in blood and lead segments was measured with a gamma counter. Platelet deposits were denser on silicone leads (441.58 +/- 915.0 to 2.19 +/- 2.07) than on polyurethane leads (1.21 +/- 1.33 to 0.27 +/- 0.14) (P > 0.05). Denser platelet deposits were detected at the tip of all leads. Density of platelet deposits declined from tip to distal segments in silicone leads. The percentage of injected platelet radioactivity in the lungs of pigs with either silastic leads (12.9 +/- 2.3%) of polyurethane leads (10.1 +/- 2.2%) was higher than in the controls (4.6 +/- 0.5%) (P < 0.05). This difference indicates thrombus formation and embolization in the lungs early after lead implantation. Thrombogenicity of polyurethane leads may be lower than that of silicone leads.

Venous complications after insertion of a transvenous pacemaker

We reviewed the incidence, clinical features, current diagnostic evaluations, and treatments of venous complications that can occur after implantation of a transvenous pacemaker. Of the approximately 80 published articles on the potential venous complications after implantation of a permanent transvenous pacemaker, we selected 63 that addressed the clinical features, diagnosis, and treatment of pacemaker lead-induced venous thrombosis, which occurs in approximately 30 to 45% of patients early or late after implantation of a transvenous pacemaker. Most patients with chronic deep venous thrombosis remain asymptomatic because of the development of an adequate venous collateral circulation. Clinical features of pacemaker lead-induced deep venous thrombosis, although rare, are easily recognized. They should be sought routinely during follow-up of all patients with transvenous pacemaker leads because venous obstruction can interfere with intravenously administered therapy, monitoring of central venous pressure, and revision of a pacemaker lead. Acute deep venous thrombosis is likely to be symptomatic. Early recognition and treatment of acute deep venous thrombosis may help to decrease the potential morbidity and mortality. The definitive diagnosis of pacemaker lead-induced venous thrombosis necessitates contrast-enhanced or digital subtraction venography. Management includes anticoagulation, thrombolytic therapy, surgical intervention, and, recently, percutaneous transluminal balloon venoplasty and depends on the duration, extent, and site of venous occlusion as well as the accompanying symptoms.

Complications after single versus dual chamber pacemaker implantation

To compare the complication rate in patients having a dual chamber versus a single chamber pacing system, 337 consecutive procedures performed during a 3-year period were analyzed prospectively. Two hundred fifty-eight patients (77%) received a VVI pacemaker and 75 (23%) a DDD unit. Thirteen VVI (5%) and 4 DDD (5.3%) needed reintervention. Lead displacement with reoperation was required for three ventricular leads (1%) and one atrial lead (1.3%). Infection occurred in two VVI units (0.77%) and one DDD (1.33%) unit. Muscular stimulation was noticed among three DDD (4%) and nine VVI systems (3.5%). Urgent reprogramming was needed for 23 VVI (9%) and six DDD units (8%). There was no increase in complications with dual chamber pacing compared to single chamber systems.

Digital subtraction venography for assessment of deep venous thrombosis in the arms following pacemaker implantation

We recently performed digital subtraction venography and detected axillary venous thrombosis in a 56-year-old female with nonspecific symptoms related to the right arm following a permanent transvenous endocardial pacemaker implantation two years ago. In view of its cost-effectiveness and less invasive approach, digital venography appears ideally suited for evaluation of the frequently occurring subclinical deep venous thrombosis in these patients.

Functionless retained pacing leads in the cardiovascular system. A complication of pacemaker treatment

Twenty one patients with retained endocardial pacemaker leads were followed during a total observation period of 1097 months to assess the incidence of complications. Two patients developed thrombosis and occlusion of the superior vena cava, which was relieved by the development of a collateral venous circulation. In one patient the broken tip of the lead migrated to a pulmonary artery but did not cause overt complications. The remaining patients were free of symptoms. One patient died for reasons unconnected with pacemaker treatment. The good toleration of retained pacemaker leads by most patients indicates that major surgical procedures to remove the lead should be reserved for patients with life threatening complications, such as persistent infection or dangerous migration of the lead or both.

Venous gangrene of the upper extremity

Gangrene of the hand associated with acute upper extremity venous insufficiency has been seen in four limbs in three patients treated at Vanderbilt University Medical Center. All three patients had life-threatening illnesses associated with diminished tissue perfusion, hypercoagulability, and venous injury. One patient progressed to above-elbow amputation, but venous thrombectomy in one limb and thrombolytic therapy in two others were successful in preventing major tissue loss. All three patients eventually died from their underlying illness. Thirteen previously reported patients with "venous gangrene" of the upper extremity have been analyzed. An underlying life-threatening illness was present in the majority of these patients (7/13, 54%) and, like the Vanderbilt series, amputations were frequent (7/13, 54%) and mortality (5/13, 38%) was high. This unusual form of ischemia appears to be produced by permutations of global circulatory stasis, subclavian or axillary vein occlusion, and peripheral venous thrombosis. Early, aggressive restoration of adequate cardiac output and thrombectomy and/or thrombolytic therapy may provide the best chance for tissue salvage and survival in this group of patients.

Ventricular thrombosis during permanent endocardial pacing in a pediatric patient with hemorrheological disorders

Thrombosis in the right atrium or ventricle is a rare complication of permanent endocardial pacing in adults. To the best of our knowledge, this complication has not been previously reported at all in the pediatric age group. We report on a case of a 7-year-old boy who had large left ventricular thrombi that occurred during permanent endocardial electrical stimulation. Subsequent pulmonary emboli complicated congestive heart failure in this patient. As a diagnostic approach, echocardiography and pulmonary perfusion scintigraphy were used. We comment on possible causes of this serious complication and suggest hemorrheological and platelet activation studies in patients with permanent endocardial pacing.

Symptomatic upper extremity venous thrombosis associated with permanent transvenous pacemaker electrodes

Symptomatic arm vein thrombosis secondary to permanent transvenous cardiac pacing electrodes is an uncommon occurrence with an incidence of 1 to 3 percent. Two patients with this problem are presented who were treated with streptokinase followed by conventional anticoagulation therapy with heparin and warfarin. Near total resolution of the thromboses was accomplished in both patients. In follow-up periods of nine and 20 months, the patients have remained asymptomatic. An aggressive approach to this problem may decrease the current high morbidity.

Thrombosis of the subclavian vein--a rare complication of transvenous cardiac pacing

Thrombosis of the central veins as a complication of transvenous cardiac pacing fortunately is rare. A case is presented in which symptomatic thrombosis of the subclavian vein arose seven weeks after implantation of a new electrode. The frequency, pathogenesis, clinical picture, complications and treatment of the condition are briefly discussed.

Evidence of low-grade intravascular coagulation in patients with transvenous pacemakers

Serum fibrin and fibrinogen degradation products (FDP) were measured in 4 groups of patients. In Group A (30 patients) FDP levels were measured before and 48-60 hours after pacemaker and transvenous electrode placement. They remained negative (less than 10 micrograms/ml) in 14, rose to greater than 10 micrograms/ml less than 40 micrograms/ml in 12, and greater than 40 micrograms/ml in 4. In 12 Group B patients undergoing the same procedure, FDP levels remained negative in 8, and rose in 4 after 24 hours and after 7 days. In 12 Group C patients studied at initial electrode and battery implantation and 3-6 months later, there were the same results in short- and long-term FDP measurements (8 negative and 4 elevated). Finally, in 14 patients with negative FDP levels who underwent battery replacement only, 3.1 to 5.2 years after their initial operation (Group D), no increase of FDP titer was seen postoperatively. Our results suggest that elevated FDP levels suggest subclinical intravenous or intracardiac thrombosis in patients with transvenous pacemakers.

Problems encountered during insertion of permanent endocardial pacing electrode

Case reports of two potential problems arising during permanent endocardial pacemaker electrode insertion are described. They are cannulation of a persistent left-sided superior vena cava, and unsuspected subclavian vein thrombosis. A left-sided superior vena cava may be recognized clinically and avoided; but, if necessary, it can be employed as a route to the right ventricular endocardium. Subclavian vein thrombosis appears to be a complication of previous cephalic vein pacemaker insertion and prohibits further access on the implanted side. It may present with a painful, swollen arm or with the symptoms of multiple pulmonary emboli; occasionally it is not clinically suspected unless abnormal venous distension is sought.

An unusual complication of the unremoved unwanted pacing wire

A case of external jugular vein thrombosis is described. This occurred following failure to remove an unwanted pacing wire by sustained traction and its subsequent migration from the subclavian vein into the external jugular vein.

Superior vena cava syndrome complicating transvenous cardiac pacing. An occult cause for repeated A-V fistula failure

Four attempts to construct an arteriovenous fistula in the arms of a patient with chronic uremia resulted in occlusion of the fistulae. This was caused by superior vena cava syndrome which, in turn, was a late complication of transvenous pacing. A fistula was subsequently successfully constructed in a lower extremity.