Solved on SIR Connect By Patrick Moran, MD, Jackson Bennett, MD, Sudhen B. Desai, MD, FSIR, and Faraj Hanna Al-Kass, MD


Feedback on angioplasty around pacemaker wires


Original post, lightly edited for flow: bit.ly/44Z2KTt


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.


Please elaborate on the specific patient background and presentation in this case. Faraj Hanna Al-Kass, MD: 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.


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


AUTHOR NAME AND CONTACT INFORMATION


Faraj Hanna Al-Kass, MD California Vascular Health Institute Info@vivavein.com


18 IRQ | FALL 2023


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


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


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40