Solved on SIR Connect

Feedback on angioplasty around pacemaker wires

Original post, lightly edited for flow:

Patient with pacemaker has a great working anastomotic left brachiocephalic dialysis fistula but previously presented with noncrossable chronic axillary vein obstruction and ended with cephalic vein/graft to L internal jugular vein bypass. Lately, she presented with subclavian/brachiocephalic occlusion. In these cases, because of the wires, the vein can't be reconstructed properly. There is also risk of dislodging/perforating the wires. Additionally, I think the minute the patient leaves the angiography suite, thrombotic process is back in business despite adequate AC. Appreciate any feedback and solutions for similar situations.

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• Image 1: Dialysis circuit angiogram delineating the jump graft placed between the left cephalic and internal jugular veins. A short segment of graft-cephalic venous anastomosis stenosis is present.

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• Image 2: Pre-intervention angiogram revealing brachiocephalic occlusion and prominent surrounding venous collaterals.

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• Image 3: Post-angioplasty demonstrating brachiocephalic recanalization, improved flow and resolution of surrounding venous collaterals.

1. Author name and contact information? 

Faraj Hanna Al-Kass, MD

California Vascular Health Institute

Info@vivavein.com

2. Please elaborate on the specific patient background and presentation in this case. 

The patient has a history of end-stage renal disease on hemodialysis via a left brachiocephalic arteriovenous fistula with jump graft from cephalic vein to internal jugular vein. The patient presented with a history of chronic left subclavian vein occlusion around the wires of a pre-existing pacemaker and recurrent left upper extremity and facial swelling. The patient previously had arm swelling the prior fall that improved after prior angioplasty.

3. What are the collaborating roles of IRs and electrophysiology (EP) when considering angioplasty around pacemaker wires or lead extraction/removal?

In my opinion, pacemaker lead extraction (distal leads are embedded in the myocardium) is the main responsibility of the electrophysiology cardiologist. Invariably, leads are left in place unless they become infected. With the newly available FDA-approved leadless single chamber pacemaker, the goal would be to initiate discussions about this technology with our cardiology colleagues. The consequence of pacemaker leads and interventions can be debilitating for patients.

4. What ended up being the outcome for this patient? Is there anything you would do differently in retrospect?

Because the jump graft to the internal jugular vein anastomosis was such an acute angle, it was challenging to perform intervention on the brachiocephalic occlusion. Femoral access was obtained, and we were able to establish through and through access in the inferior vena cava. Multiple sessions of angioplasty were then performed on the occluded brachiocephalic vein using an 8mm balloon, which was subsequently recanalized. The patient’s left cephalic vein-graft anastomosis was also angioplastied with satisfactory flow. The decision was then made to monitor the patient for left arm swelling and discuss with cardiology other pacemaker/brand wireless options so brachiocephalic flow can be reconstructed.

5. Will you, or have you changed your practice patterns based off responses on SIR Connect? Please describe any changes you are considering. 

I was hoping to post and have some discussion on SIR Connect to see if other IRs have had conversations with cardiology colleagues about the pacemakers and how to work with them, to make the transition and into a leadless pacemaker era. I understand this is a learning curve for cardiologists, and some will doubt new devices—especially cardiology veterans. I am happy that we have a chance to shed light on the subject.

Discussion

Central venous stenosis (CVS) following placement of cardiac implanted electronic devices (CIEDs) is a well-known complication. The incidence of stenosis has been quoted in the literature to range from 14–60%.1–2 Total venous occlusions have been reported in up to 6% of patients at 6 months and 26% at 6 year mark in patients who required CIED revision.3 Clinically CVS is often asymptomatic due to collateral formation and are often discovered incidentally.4 In patients with ipsilateral arteriovenous fistula (AVF) the high flow rates increase the risk venous hypertension.5–6 Often patients with CVS do not require treatment unless they are symptomatic with significant arm swelling, SVC syndrome, or have poor functioning AVF and dialysis access as a result.  

Main therapeutic options in these patients include venoplasty ± stenting, lead extraction with venoplasty ± stenting, contralateral implantation of new CIED or placement of a “leadless pacemaker.”2 In a multicenter study, 27 patients with CVS, ipsilateral hemodialysis (HD) access and symptomatic swelling were treated with conventional balloon angioplasty with a 100% clinical success rate. Primary patency at 6 and 12 months was 18% and 9% respectively. Secondary patency defined as patency until access was revised or abandoned was 95%, 86% and 73% at 6, 12 and 24 months, respectively. A mean of 2.1 procedures⁄year were required to maintain secondary patency and no procedural complications were encountered.8 A study of 14 dialysis patients with ipsilateral HD arteriovenous (AV) access who had symptomatic central venous stenosis or occlusion were treated with angioplasty and stenting to evaluate patency rates and complications with the CIED leads. Lesions that failed to respond to angioplasty with >30% residual stenosis or short interval (3 month) restenosis were considered for stenting. Primary patency at 6 and 12 months was 45% and 9% respectively. Secondary patency rates were 100% and 90% at 12 and 6 months. Mean number of interventions per patient per year was 2.1. There was no CIED device dysfunction or lead failure after stenting. No patient required cardiac rhythm device removal or exchange.9

The obvious concern with stenting over CIED leads are damage to leads and “entrapping” leads, making future extraction very challenging. The authors argue that leads are manufactured with a very robust multilayered coating that is quite resistant to mechanical damage. Lead entrapment becomes an issue when a patient has endovascular infection or failed antibiotics and laser removal of leads becomes impossible, thus requiring an open surgical procedure. While this is true, it is discussed that with the high mortality rate associated with HD patients, long-term survival may not be achievable. In these situations, keeping the patient out of the hospital, reducing the number of procedures, preserving their AV access and reducing morbidity of venous catheter placements should be of utmost importance.9 Balancing the theoretical risk of possible need for future CIED lead extraction versus immediately preserving HD access is a discussion that should be had with the patient and their care team.

New devices and “leadless pacemakers” placed via transfemoral approach into the right ventricle may be an alternative to the traditional transvenous pacemakers and can decrease lead-associated CVS in HD patients. Leadless pacemakers, however, have limited pacing modalities and memories, so use of these devices will depend on the clinical indication for pacing.10 It is therefore essential that when caring for complex HD access patients who require CIEDS there is a multidisciplinary discussion between electrophysiologists, vascular access surgery and interventional radiologists prior to device placement, AVF creation or interventions.

References:

  1. Spittell PC, Hayes DL. Venous complications after insertion of a transvenous pacemaker. Mayo Clin Proc. 1992;67:258–265.
  2. Oginosawa Y, Abe H, Nakashima Y. The incidence and risk factors for venous obstruction after implantation of transvenous pacing leads. Pacing Clin Electrophysiol. 2002;25:1605–1611. 
  3. Abu-El-Haija B, Bhave PD, Campbell DN, Mazur A, Hodgson-Zingman DM, Cotarlan V, et al. Venous stenosis after transvenous lead placement: A study of outcomes and risk factors in 212 consecutive patients. J Am Heart Assoc. (2015)4:e001878. doi: 10.1161/JAHA.115.001878.
  4. Lickfett L, Bitzen A, Arepally A, Nasir K, Wolpert C, Jeong KM, et al. Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement. Europace. (2004) 6:25–31. doi: 10.1016/j.eupc.2003.09.001. 
  5. Korzets A, Chagnac A, Ori Y, Katz M, Zevin D. Subclavian vein stenosis, permanent cardiac pacemakers and the haemodialysed patient. Nephron 1991;58:103–5. 
  6. Teruya TH, Abou-Zamzam AM, Limm W, Wong L, Wong L. Symptomatic subclavian vein stenosis and occlusion in hemodialysis patients with transvenous pacemakers. Ann Vasc Surg. 2003; 17: 526–9.
  7. Domenichini G, Le Bloa M, Carroz P, Graf D, Herrera-Siklody C, Teres C, Porretta AP, Pascale P, Pruvot E. New Insights in Central Venous Disorders. The Role of Transvenous Lead Extractions. Front Cardiovasc Med. 2022 Feb 23;9:783576. doi: 10.3389/fcvm.2022.783576. PMID: 35282352; PMCID: PMC8904723. 
  8. Asif A, Salman L, Carrillo RG, Garisto JD, Lopera G, Barakat U, Lenz O, Yevzlin A, Agarwal A, Gadalean F, Sachdeva B, Vachharajani TJ, Wu S, Maya ID, Abreo K. Patency rates for angioplasty in the treatment of pacemaker-induced central venous stenosis in hemodialysis patients: Results of a multi-center study. Semin Dial. 2009 Nov-Dec;22(6):671-6. doi: 10.1111/j.1525-139X.2009.00636.x. Epub 2009 Oct 2. PMID: 19799756.
  9. Saad TF, Myers GR, Cicone J. Central vein stenosis or occlusion associated with cardiac rhythm management device leads in hemodialysis patients with ipsilateral arteriovenous access: a retrospective study of treatment using stents or stent-grafts. J Vasc Access. 2010 Oct-Dec;11(4):293–302. doi: 10.5301/jva.2010.1064. PMID: 20658455. 
  10. El-Chami MF, Clementy N, Garweg C, Omar R, Duray GZ, Gornick CC, Leyva F, Sagi V, Piccini JP, Soejima K, Stromberg K, Roberts PR. Leadless pacemaker implantation in hemodialysis patients: Experience with the Micra Transcatheter pacemaker. JACC Clin Electrophysiol. 2019 Feb;5(2):162–170. doi: 10.1016/j.jacep.2018.12.008. Epub 2019 Jan 30. PMID: 30784685.

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