Lead Management

-SVC Occlusion

2017

Steven P. Kutalek, MD, FACC, FHRS

Director, Cardiac Electrophysiology & Pacing

Drexel University College of Medicine

Documented total venous occlusion rates

– 30 – 50 %

– Demonstrated by venography

– Surrounding area of lead insertion, usually

subclavian near cephalic entry site

– May extend into the SVC

– Isolated SVC stenosis or occlusion may also occur

Historical - Chronic Occlusions

SVC OcclusionPrinciples

Occurring with increasing frequency

Requires extraction to obtain a conduit for re-

implantation

Unlikely to remain open, even if “debulked” with

LASER

Risk of extraction more related to known overall

patient risk factors (such as degree of fibrosis and

BMI) rather than to occlusion itself

Vascular overload with leadsLead on lead adherence and scarring

Adherence of the bulk of leads to the vascular wall

HRS recommendations < 5 leads via SVC

Tendency to scarYoung age

Renal patients

SVC ICD coils

Long implant duration

SVC OcclusionCauses

Risk of Future Lead Extraction

> 3500 leads in 266 centers

2-fold increase in the risk of extraction failure with

every 3 years of implant duration 1

212 consecutive patients

3.5-fold increase in TLE complications per additional

right ventricular lead extracted

50% increase in the need for powered sheath

assistance per year increase in implant duration of the

oldest lead 2

1. Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Turk KT, Reeves R, Young R, Crevey B, Kutalek SP, Freedman R, Friedman R, Trantham J, Watts M,

Schutzman J, Oren J, Wilson J, Gold F, Fearnot NE, Van Zandt HJ. Intravascular extraction of problematic or infected permanent pacemaker

leads: 1994–1996. U.S. Extraction Database, MED Institute. Pacing Clin Electrophysiol. 1999;22:1348–1357

2. Agarwal SK, Kamireddy S, Nemec J, Voigt A, Saba S. Predictors of complications of endovascular chronic lead extractions from pacemakers and

defibrillators: a single-operator experience. J Cardiovasc Electrophysiol. 2009;20:171–175

Case 1Background

46 year old male federal law enforcement officer

Very active life style

Acquired complete heart block

Case 1Pacing History

Dual chamber pacemaker left subclavian site

1996 (age 28)

Pulse generator replacement in 2002 (age 34)

– Increasing RV pacing threshold 3 V

MDT bipolar screw-in 4068 extracted

MDT bipolar screw-in 5076 implanted

Pulse generator end of service 2011 (age 43)

– LVEF 35 % - Echo

– LVEF 39 % - Nuclear

No ischemia, no scar

Interventions in 2011

– Coronary sinus lead placed BSCI 4542

– RA lead insulation repair sleeve (Intermedics

coradial bipolar Thin Line 432-04)

LVEF Improved to >40 %

Case 1Pacing History

Progressive symptoms of class III CHF in 2014

age 46)High LV pacing threshold

Fluoroscopy – lead fracture of CS lead in the pocket

Venography showed complete occlusion of left

Brachiocephalic vein and SVC

Case 1Pacing History

Cap the old CS lead and place a new CS lead

on the right side and tunnel it to the left side

Do the same with the RA lead

Extract the CS (and RA) lead(s) and use

extraction conduits for replacement

Case 1Options

Case 1Pacing History

CS and RA leads were extractedLaser to form conduits over both leads

Conduits used for re-implantation of new RA and CS leads

LVEF improved to 55 %

Venous Occlusion in ICD Patients

Venography at the time of ICD generator replacement

9% of patients had complete occlusion of the access

vessel

25% had some degree of stenosis

67 % risk of some obstruction in pts with a pacemaker

before placement of the ICD

17 % risk of obstruction in pts with just single leads

Lickfett L, Bitzen A, Arepally A, Nasir K, Wolpert C, Jeong KM, Krause U, Schimpf R, Lewalter T, Calkins H, Jung W,

Luderitz B. 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

Case 2

• 84 year old male with NYHA II

• PM in place

• Wide QRS – paces 100 %

• Arms swell with activity – L > R

• Device at ERI

What would you do?

• 1. Extract to open the SVC and to make a conduit for new leads

• 2. Just replace the PM generator

Need to maintain access with long wires after the

conduit is established

Use long sheaths to pass the area of occlusion for

re-implantation

Be sure to establish a conduit with the extraction

sheath before the lead is removed

Extraction through OcclusionsCaveats

Case 3

Case 4

Venous dilatation (and even venous stents) do not

always remain open for the long termLow pressure in the venous system

Continued irritation by intra-vascular leads

Decision to pursue this moderate risk procedure

needs to be individualized

SVC occlusion precludes use of the Bridge balloon

SVC OcclusionConclusions