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Images in cardiovascular medicine

Leadless pacemaker placement to overcome bilateral subclavian vein occlusion

DOI: https://doi.org/10.4414/cvm.2022.w10127
Publication Date: 19.05.2022
Cardiovasc Med. 2022;25:w10127

Patrick Badertscher, Philip Haaf, Christian Sticherling, Stefan Osswald

Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland

We present the case of a 76-year-old man referred for dual chamber pacemaker implantation for high-grade atrioventricular block. Prior to dual-chamber pacemaker implantation, the following contrast venograms are obtained. How do you proceed?

Contrast venography demonstrated occlusion of the left subclavian vein with extensive formation of collateral veins. Contrast venography of the right subclavian vein showed a similar obstruction (fig. 1). There were no clues in the patient’s history as to the cause of the venous obstructions: no trauma, radiation, or intravascular procedures were reported. Computed tomography angiography of the chest (fig. 2) confirmed hypoplastic, filiform subclavian veins, which represents an uncommon vascular phenomenon [1]. In patients in whom the traditional transvenous route is not available, different techniques may be used to overcome this difficulty: (1) epicardial placement of electrodes via surgical approach; (2) “inside-out” access: by obtaining femoral access various tools such as stiff angioplasty wires, laser extraction tools or even a trans-septal kit have been described to allow penetration of the proximal edge of the occluded segment of the subclavian vein towards the distal edge of occlusion; (3) implantation of a leadless pacemaker using right femoral access [2]. We chose the last option because of its simplicity and safety profile and the availability of AV-synchronous pacing with the latest device (MICRA AV, Medtronic, Minneapolis, MN) [3]. The ECG at discharge (fig. 3) confirmed VDD pacing (by detection of atrial contraction by the accelerometer). In the new 2021 European Society of Cardiology (ESC) guidelines for cardiac pacing and cardiac resynchronisation therapy [4], DDD should be preferred over single chamber ventricular pacing in the case of atrioventricular block and underlying sinus rhythm (recommendation class IIa, level A). Leadless pacemaker placement has now a class IIb recommendation (level B) for indications such as obstruction of the venous route, pocket issues or increased infection risk. In certain circumstances assessment of atrial function by clinical ­parameters, echocardiographic markers or sinus rate ­variability at rest to predict a high percentage of atrioventricular-synchronous pacing may help in patient selection for leadless VDD pacing.

In summary, percutaneous, leadless pacemaker placement may be considered in cases with bilateral total vein occlusion.

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Figure 1:

Contrast venography demonstrating bilateral subclavian vein stenosis.

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Figure 2:

Multiplanar 3D reconstruction of extensive collaterals, right internal jugular vein draining into SVC. Inlay with * showing axial computed tomography slice of filiform bridging vein. SVC = superior vena cava; RIJV = right internal jugular vein

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Figure 3:

ECG at discharge confirmed atrioventricular-synchronous pacing by detection of atrial contraction by the ­accelerometer.

Disclosure statement

No financial support and no other potential conflict of interest relevant to this article was reported.

Correspondence

Patrick Badertscher, MD

Department of Cardiology

University Hospital Basel

Petersgraben 4

CH-4031 Basel

patrick.badertscher[at]usb.ch

References

1. Lickfett L, Bitzen A, Arepally A, Nasir K, Wolpert C, Jeong KM 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 Jan;6(1):25–31. http://dx.doi.org/10.1016/j.eupc.2003.09.001 PubMed

2. Elayi CS, Allen CL, Leung S, Lusher S, Morales GX, Wiisanen M Inside-out access: a new method of lead placement for patients with central venous occlusions. Heart Rhythm. 2011 Jun;8(6):851–7. http://dx.doi.org/10.1016/j.hrthm.2011.01.024 PubMed

3. Steinwender C, Khelae SK, Garweg C, Chan JY, Ritter P, Johansen JB Atrioventricular Synchronous Pacing Using a Leadless Ventricular Pacemaker: Results From the MARVEL 2 Study. JACC Clin Electrophysiol. 2020 Jan;6(1):94–106. http://dx.doi.org/10.1016/j.jacep.2019.10.017 PubMed

4. Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, ESC Scientific Document Group. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021 Sep;42(35):3427–520. http://dx.doi.org/10.1093/EURHEARTJ/EHAB364   http://dx.doi.org/10.1093/eurheartj/ehab364 PubMed

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