Closure Access Leading Venous Advanced Gain New Ability: A New Technique To Overcome Implantable Device Venous Occlusion

Implantable cardiac devices have become a standard therapy for patients with heart rhythm disturbances. However, infectious and non-infectious complications requiring device extraction represent a limit of this therapy [ 1 Scarano M. Pezzuoli F. Torrisi G. Calvagna G.M. Patanè S. Cardiovascular implantable electronic devices infective endocarditis. Int. J. Cardiol. May 15 2014; 173: e38-e39 Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar , 2 Calvagna G.M. Ceresa F. Patanè S. Subcutaneous implantable cardioverter–defibrillator in a young woman. Int. J. Cardiol. Aug 1 2014; 175: e30-e32 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar , 3 Calvagna G.M. Patanè S. Romeo P. Ceresa F. Sansone F. Patanè F. Embolization and retrieval of an anchoring sleeve during transvenous lead extraction. Int. J. Cardiol. May 15 2014; 173: e42-e44 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar , 4 Calvagna G.M. Evola R. Scardace G. Valsecchi S. 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Pacemaker, implantable cardioverter defibrillator, CRT, CRT-D, psychological difficulties and quality of life. Int. J. Cardiol. Jun 15 2014; 174: 378-380 Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar , 9 Calvagna G.M. Ceresa F. Patanè S. Pocket infection as a complication of a subcutaneous implantable cardioverter–defibrillator. Int. J. Cardiol. Dec 15 2014; 177: 616-618 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar , 10 Calvagna G.M. Patanè S. Intravascular recovery of electrode fragments as a possible complication of transvenous removal intervention. Int. J. Cardiol. Dec 15 2014; 177: 560-563 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar , 11 Romeo P. Calvagna G.M. Giunta M. Vitale F.V. Patanè S. Removal of an intracardiac lost port — a catheter utilizing a simple low-cost method. Int. J. Cardiol. Oct 20 2014; 176: 1309-1311 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar , 12 Calvagna G.M. Patanè S. 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A complete bicameral pacemaker pocket decubitus. Int. J. Cardiol. Dec 24 2014; 181C: 340-343 Google Scholar , 18 Ward C. Henderson S. Metcalfe N.H. A short history on pacemakers. Int. J. Cardiol. Nov 15 2013; 169: 244-248 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar , 19 Bradshaw P.J. Stobie P. Knuiman M.W. Briffa T.G. Hobbs M.S. Life expectancy after implantation of a first cardiac permanent pacemaker (1995–2008): a population-based study. Int. J. Cardiol. Jul 1 2015; 190: 42-46 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar , 20 Zeb M. Curzen N. Allavatam V. Wilson D. Yue A. Roberts P. Morgan J. Sensitivity and specificity of the subcutaneous implantable cardioverter defibrillator pre-implant screening tool. Int. J. Cardiol. Sep 15 2015; 195: 205-209 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar ]. Venous occlusion sometimes precludes the ability to insert leads during placement of a cardiac implantable electronic device and can occur anytime both before [ [21] Kodani T. Mine T. Kishima H. Ashida K. Masuyama T. Spontaneous subclavian venous occlusion before electronic device implantation. Asian Cardiovasc. Thorac. Ann. Jun 2015; 23: 530-534 Crossref PubMed Scopus (3) Google Scholar ] and after initial device placement [ 22 Calvagna G.M. Patanè S. Venous occlusion after transvenous pacemaker implantation — is there a role for new oral anticoagulants?. Cardiovasc. Drugs Ther. Feb 2015; 29: 99-100 Crossref PubMed Scopus (10) Google Scholar , 23 Calvagna G.M. Ceresa F. Morgante A. Patanè S. Transvenous extraction of a left subclavian dialysis catheter: a new challenge in cardiology. Int. J. Cardiol. Mar 10 2015; 185: 144-147 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar , 24 Calvagna G.M. Patanè S. Romeo P. Condorelli S. Vasquez L. Transvenous recovery of an intracardiac fractured port — a catheter fragment. Int. J. Cardiol. Apr 15 2015; 185: 214-217 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar , 25 Collin G. Jones R.G. Willis A.P. Central venous obstruction in the thorax. Clin Radiol. 2015 Jun; 70: 654-660 Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar ]. Central venous occlusions in device patients are often asymptomatic [ 26 Kutarski A. Pietura R. Młynarczyk K. Małecka B. Głowniak A. Pacemaker lead extraction and recapture of venous access: technical problems arising from extensive venous obstruction. Cardiol. J. 2012; 19: 513-517 Crossref PubMed Scopus (12) Google Scholar , 27 Sohal M. Williams S. Akhtar M. Shah A. Chen Z. Wright M. O'Neill M. Patel N. Hamid S. Cooklin M. Bucknall C. Bostock J. Gill J. Rinaldi C.A. Laser lead extraction to facilitate cardiac implantable electronic device upgrade and revision in the presence of central venous obstruction. Europace. Jan 2014; 16: 81-87 Crossref PubMed Scopus (42) Google Scholar ] due to the development of an adequate venous collateral circulation. Nonetheless, occlusions can cause difficulties during device revision/upgrade/extraction and may require longer procedure time and the use of advanced tools [ 26 Kutarski A. Pietura R. Młynarczyk K. Małecka B. Głowniak A. Pacemaker lead extraction and recapture of venous access: technical problems arising from extensive venous obstruction. Cardiol. J. 2012; 19: 513-517 Crossref PubMed Scopus (12) Google Scholar , 28 Li X. Ze F. Wang L. Li D. Duan J. Guo F. Yuan C. Li Y. Guo J. Prevalence of venous occlusion in patients referred for lead extraction: implications for tool selection. Europace. 2014 Dec; 16: 1795-1799 Crossref PubMed Scopus (46) Google Scholar ]. Several locations of venous occlusion have been described in pacemaker patients including the superior vena cava (SVC) [ 29 Ceresa F. Sansone F. Patanè S. Calvagna G.M. Patanè F. Superior vena cava obstruction as late complication of biventricular pacemaker implantation: surgical replacement of the malfunctioning previous leads. Int. J. Cardiol. Oct 20 2014; 176: e83-e85 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar , 30 Gebreyes A.T. Pant H.N. Williams D.M. Kuehl S.P. Be aware of wires in the veins: a case of superior vena cava syndrome in a patient with permanent pacemaker. J. Community Hosp. Intern. Med. Perspect. Oct 15 2012; 2 PubMed Google Scholar , 31 Rossi A. Baravelli M. Cattaneo P. Romano M. Mariscalco G. Imperiale D. Rossi M.C. Picozzi A. Dario P. Anza C. Montenero A.S. Acute superior vena cava syndrome after insertion of implantable cardioverter defibrillator. J. Interv. Card. Electrophysiol. 2008; 23: 247-249 Crossref PubMed Scopus (14) Google Scholar ], subclavian vein [ 32 Kurisu S. Inoue I. Kawagoe T. Occlusion of the subclavian vein after pacemaker implantation. Intern. Med. 2008; 47 (Epub 2008 Jul 1): 1279 Crossref PubMed Scopus (5) Google Scholar , 33 Vyselaar J.R. Michael K.A. Nolan R.L. Baranchuk A. Left subclavian vein occlusion after pacemaker insertion. Cardiovasc. J. Afr. May–Jun 2008; 19: 155 PubMed Google Scholar ], axillary vein [ [34] Breuls N.P. Res J.C. Acute subclavian or axillary vein occlusion during biventricular pacemaker implantation. Pacing Clin. Electrophysiol. Oct 2006; 29: 1170-1173 Crossref PubMed Scopus (10) Google Scholar ], inferior vena cava (IVC) [ [35] Schroeter T. Dähnert I. Doll N. Mohr F.W. Borger M.A. Pacemaker-associated thrombotic occlusion of the inferior vena cava causing liver failure. Thorac. Cardiovasc. Surg. Oct 2010; 58: 431-433 Crossref PubMed Scopus (8) Google Scholar ], subtotal innominate vein [ [36] Van Putte B.P. Bakker P.F. Subtotal innominate vein occlusion after unsuccessful pacemaker implantation for resynchronization therapy. Pacing Clin. Electrophysiol. Nov 2004; 27: 1574-1575 Crossref PubMed Scopus (7) Google Scholar ], and internal jugular vein [ [37] Fitzgerald S.P. Leckie W.J. Thrombosis complicating transvenous pacemaker lead presenting as contralateral internal jugular vein occlusion. Am. Heart J. Mar 1985; 109: 593-595 Abstract Full Text PDF PubMed Scopus (16) Google Scholar ]. Upper extremity deep vein thrombosis has also been described in patients with pacemaker [ [38] Mandal S. Pande A. Mandal D. Kumar A. Sarkar A. Kahali D. Mazumdar B. Panja M. Permanent pacemaker-related upper extremity deep vein thrombosis: a series of 20 cases. Pacing Clin. Electrophysiol. Oct 2012; 35: 1194-1198 Crossref PubMed Scopus (25) Google Scholar ] and the following factors have been found to facilitate it: diabetes, smoking, hypertension, obesity with body mass index ≥30, history of acute myocardial infarction, chronic obstructive pulmonary disease and history of congestive cardiac failure (15%). In these cases, anticoagulation therapy but not antiplatelets therapy was shown to be effective [ [38] Mandal S. Pande A. Mandal D. Kumar A. Sarkar A. Kahali D. Mazumdar B. Panja M. Permanent pacemaker-related upper extremity deep vein thrombosis: a series of 20 cases. Pacing Clin. Electrophysiol. Oct 2012; 35: 1194-1198 Crossref PubMed Scopus (25) Google Scholar ]. Additional factors possibly associated with pacing lead-related venous thrombosis are atrial fibrillation, foreign body-type reaction, and hypercoagulability [ [39] Ayhan S.S. Oztürk S. Ozlü M.F. Düzenli S. Recurrent pacemaker lead thrombosis in a patient with gene polymorphism: a rare case treated with thrombolytic therapy. Turk Kardiyol. Dern. Ars. Jan 2013; 41: 64-67 Crossref PubMed Scopus (4) Google Scholar ]. Notably, at the time of system removal implantable cardioverter defibrillator leads, especially after long dwell-time, have been found to be frequently affected by fibrous adherences along the lead course, complicating the procedure [ [40] Segreti L. Di Cori A. Soldati E. Zucchelli G. Viani S. Paperini L. De Lucia R. Coluccia G. Valsecchi S. Bongiorni M.G. Major predictors of fibrous adherences in transvenous implantable cardioverter–defibrillator lead extraction. Heart Rhythm. 2014 Dec; 11: 2196-2201 Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar ]. We usually search to remove the preexisting electrodes with a percutaneous approach but if the adhesions between the leads and the venous wall cannot be gone over, in our mind, the surgical strategy is often mandatory [ 41 Calvagna G.M. Patanè S. Severe staphylococcal sepsis in patient with permanent pacemaker. Int. J. Cardiol. Apr 1 2014; 172: e498-e501 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar , 42 Calvagna G.M. Patanè S. Intravascular recovery of electrode fragments as a possible complication of transvenous removal intervention. Int J Cardiol. 2014 Dec 15; 177: 560-563 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar , 43 Calvagna G.M. Patanè S. Transvenous pacemaker lead extraction in infective endocarditis. Int. J. Cardiol. Sep 20 2014; 176: 511-513 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar ]. Nowadays prevention of pacing venous occlusions represents an increasing serious challenge as well its optimal management. Furthermore, perioperative lead extraction management varies between extraction centers, and no clinical guidelines [ [44] Wilkoff B.L. Love C.J. Byrd C.L. Bongiorni M.G. Carrillo R.G. Crossley III, G.H. Epstein L.M. Friedman R.A. Kennergren C.E. Mitkowski P. Schaerf R.H. Wazni O.M. Heart Rhythm SocietyAmerican Heart AssociationTransvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm. 2009; 6 (1085e104) Abstract Full Text Full Text PDF Scopus (924) Google Scholar ] have focused on the need for anticoagulation nevertheless routine peri-operative anticoagulation and post-operative anticoagulation have been advocated as a means to prevent vein occlusions including pulmonary embolism [ 45 Hanninen M. Cassagneau R. Manlucu J. Yee R. Extensive thrombosis following lead extraction: further justification for routine post-operative anticoagulation. Indian Pacing Electrophysiol. J. May 25 2014; 14 (eCollection 2014 May.): 150-151 Crossref PubMed Scopus (9) Google Scholar , 46 Zacà V. Marcucci R. Parodi G. Limbruno U. Notarstefano P. Pieragnoli P. Di Cori A. Bongiorni M.G. Casolo G. Management of antithrombotic therapy in patients undergoing implantation or replacement of cardiac implantable electronic devices. G. Ital. Cardiol. (Rome). Jan 2014; 15: 56-72 PubMed Google Scholar ]. NOACs may find a possible application also in this emerging clinical scenario [ [22] Calvagna G.M. Patanè S. Venous occlusion after transvenous pacemaker implantation — is there a role for new oral anticoagulants?. Cardiovasc. Drugs Ther. Feb 2015; 29: 99-100 Crossref PubMed Scopus (10) Google Scholar ]. Until now we used the mechanical multiple venous entry-site approach extraction technique previously described by other authors [ [47] Bongiorni M.G. Soldati E. Zucchelli G. Di Cori A. Segreti L. De Lucia R. Solarino G. Balbarini A. Marzilli M. Mariani M. Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads. Eur. Heart J. Dec 2008; 29: 2886-2893 Crossref PubMed Scopus (207) Google Scholar ] for removal of pacing and ICD leads and it was usually successful and safe when performed by well-trained operators with few serious complications [ [4] Calvagna G.M. Evola R. Scardace G. Valsecchi S. Single-operator experience with a mechanical approach for removal of pacing and implantable defibrillator leads. Europace. Nov 2009; 11: 1505-1509 Crossref PubMed Scopus (43) Google Scholar ] even in the presence of venous occlusions. After informed consent had been obtained, the extraction procedures are performed in the electrophysiology laboratory under sedation and continuous arterial blood pressure and oxygen saturation monitoring, with cardiothoracic surgery standby available. The degree of pacemaker dependency should be preliminary assessed and stable temporary pacing established if necessary. The procedure adopted has been previously and extensively described [ [47] Bongiorni M.G. Soldati E. Zucchelli G. Di Cori A. Segreti L. De Lucia R. Solarino G. Balbarini A. Marzilli M. Mariani M. Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads. Eur. Heart J. Dec 2008; 29: 2886-2893 Crossref PubMed Scopus (207) Google Scholar ]. In brief, after device removal, a standard stylet is inserted into the lead and extraction is attempted by means of gentle traction. If this proved unsuccessful, a multiple venous entry-site approach is used. A modified mechanical dilatation technique (single-sheath rotation without tip counter-traction) is applied by inserting dilators (Byrd dilators) of increasing diameter (the size ranging from 7 to 16 F) through the venous lead entry site. During dilatation, traction is maintained, but avoiding lead damage and myocardium invagination or avulsion. Crossover to an internal jugular vein or a transfemoral approach is considered in the event of ineffective removal through the original entry site or in the presence of free-floating leads. In this case, the lead is grasped and pulled down in the inferior vena cava with a deflecting wire advanced via the femoral vein and then captured and retrieved with a lasso advanced through the jugular vein [ [4] Calvagna G.M. Evola R. Scardace G. Valsecchi S. Single-operator experience with a mechanical approach for removal of pacing and implantable defibrillator leads. Europace. Nov 2009; 11: 1505-1509 Crossref PubMed Scopus (43) Google Scholar ]. Used materials are shown in Fig. 1 Panel A. Despite the effectiveness and the safety of the previous technique, some mechanical problems could be improved. A promising technique has been developed in our Center by Calvagna. At the end of the extraction procedure, the lead is removed from the lumen of the large Byrd dilators. Instead of removing the dilator, we leave it in situ to facilitate the reimplantation of the new pacing lead. A J- or a Terumo guide is therefore inserted through the lumen of the Byrd dilator to overcome possible occlusion sites [Fig. 1 Panel B] and the Byrd dilator is subsequently removed [Fig. 2 Panel A]. Then, through the previously left guide in situ [Fig. 2 Panel B], venous introducers of increasing diameter (the size ranging from 7 to 16 F) [Fig. 2 Panel C] are inserted to dilate the previous vein occlusion and overcome venous obstacles. Subsequently, the guide is removed and the new lead is inserted through the lumen of the largest venous introducer. At the end, the venous introducer is removed. In our experience, this simple technique effectively complements the mechanical multiple venous entry-site approach extraction, as it allows the safe and easy delivery of the new lead overcoming possible venous occlusions. Additionally, our technique requires no expensive specialized material. Investigation on an adequately large sample is needed to verify the safety and efficacy of this technique. Fig. 2Panel A: the Byrd dilator is subsequently removed. Show full caption Panel B: the guide was left in situ. Panel C: venous introducers of increasing diameter (the size ranging from 7 to 16 F) are inserted to dilate the previous vein occlusion and overcome venous obstacles. View Large Image Figure Viewer Download Hi-res image Panel B: the guide was left in situ. Panel C: venous introducers of increasing diameter (the size ranging from 7 to 16 F) are inserted to dilate the previous vein occlusion and overcome venous obstacles.