|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 2 | Page : 56-57
Complete Occlusion of Subclavian Venous Access: An Unexpected Troubleshoot During Permanent Pacemaker Pulse-Generator Replacement
Arindam Pande1, Achyut Sarkar2, Imran Ahmed3, Naveen GS Chandra4
1 Consultant Cardiologist, Apollo Gleneagles Hospital, Kolkata, India
2 Associate Professor, Department of Cardiology, Institute of Post-Graduate Medical Education Research (IPGMER) & Seth Sukhlal Karnani (SSKM) Hospital, Kolkata, India
3 Clinical Tutor, Department of Cardiology, Medical College and Hospital, Kolkata, India
4 Assistant Professor, Department of Cardiology, Kasturba Medical College, Manipal, Karnataka, India
|Date of Web Publication||16-Jun-2015|
Dr. Arindam Pande
Apartment Number U 302, Binayak Enclave, 59 K C Ghosh Road, Kolkata 700050, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pande A, Sarkar A, Ahmed I, Chandra NG. Complete Occlusion of Subclavian Venous Access: An Unexpected Troubleshoot During Permanent Pacemaker Pulse-Generator Replacement. Heart India 2015;3:56-7
|How to cite this URL:|
Pande A, Sarkar A, Ahmed I, Chandra NG. Complete Occlusion of Subclavian Venous Access: An Unexpected Troubleshoot During Permanent Pacemaker Pulse-Generator Replacement. Heart India [serial online] 2015 [cited 2020 Jan 23];3:56-7. Available from: http://www.heartindia.net/text.asp?2015/3/2/56/158883
A 61-year-old man was admitted with an exhausted permanent VVI pacemaker, which was implanted 21 years back for a symptomatic intermittent complete heart block. Initial assesments and a pacemaker telemetry revealed acceptable parameters for the existing lead. So a pulse-generator replacement was planned keeping the original lead and the procedure was expected to be simple and uneventful. During the procedure, after the extraction of pulse generator, the old lead was found not to be suitable for connection with the new pulse-generator and no adopter was available to connect them. So it was planned to get a new lead, to be inserted through subclavian venepuncture. However, after getting the venous access there was resistance in lead insertion and the same could not be negotiated. A subclavian venography later revealed total occlusion of the the right innominate vein with collateral circulation [Figure 1]. At this point, the procedure was terminated. The old lead was insulated and kept as such, while a new pacemaker and lead were implanted on the contralateral side [Figure 2]a and b. No further complication occurred and the patient was discharged subsequently in a stable condition.
|Figure 1: Cineangigraphy of subclavian vein showing total occlusion of the the right innominate vein with collateral circulation|
Click here to view
|Figure 2: (a) Fluoroscopic image after completion of the procedure showing both the leads (b) Digital chest x-ray P-A view showing the abandoned insulated lead on the right side and the new pacemaker on the left side|
Click here to view
Venous thrombosis and stenosis at the implantation site are not very uncommon complications after pacemaker placement, with varying incidence in different series. , A study from India revealed diabetes, smoking, hypertension, obesity, previous myocardial infarction, chronic obstructive pulmonary disease (COPD), and congestive heart failure to be more frequently associated with permanent pacemaker-related upper extremity deep venous complications.  In a systematic evaluation of upper extremity deep vein lesions after cardiac device implant, Da Costa et al.  suggested previous use of transvenous temporary leads and a left ventricular ejection fraction less than 40% as independent risk factors to higher incidence of venous lesions 6 months after transvenous pacemaker implant. Advanced age (>65 years), though not qualifying as a risk factor to a higher incidence, encouraged the development of more advanced venous stenosis. In their cohort, some degree of venous lesions were detected in 64% of patients 6 months after transvenous pacemaker implant, but only 5.2% were symptomatic. Therefore, in pacemaker lead replacement procedures, an evaluation of the patency of the subclavian and innominate veins by venography is recommended.  Furthermore, in this manner, the optimal site of puncture can be assessed and possible damage to the already implanted leads could be avoided.
In our case, we did not plan for lead replacement at the onset, but had to go for the same eventually with all the inconvenience thereafter. So, from our experience we strongly recommend routine cineangiography of subclavian vein preoperatively in all the cases of permanent pacemaker lead replacement as well as pulse-generator exchange.
| Acknowledgement|| |
Special thanks to Mr. Somnath Patra, Cath Lab Technician, IPGMER and SSKM Hospital for his help in acquiring the images.
| References|| |
Splittell PC, Hayes DL. Venous complications after insertion of a transvenous pacemaker. Mayo Clin Proc 1992;67:258-65.
Sharma S, Kaul U, Rajani M. Digital subtraction venography for assessment of deep venous thrombosis in the arms following pacemaker implantation. Int J Cardiol 1989;23:135-6.
Mandal S, Pande A, Mandal D, Kumar A, Sarkar A, Kahali D, et al
. Permanent pacemaker-related upper extremity deep vein thrombosis: A series of 20 cases. Pacing Clin Electrophysiol 2012;35:1194-8.
Da Costa SS, Scalabrini Neto A, Costa R, Caldas JG, Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: A 6-month follow-up prospective study. Pacing Clin Electrophysiol 2002;25:1301-6.
Spencer WH 3 rd
, Zhu DW, Kirkpatrick C, Killip D, Durand JB. Subclavian venogram as a guide to lead implantation. Pacing Clin Electrophysiol 1998;21:499-502.
[Figure 1], [Figure 2]