Occluded superior vena cava and failed epicardial pacing: An unorthodox solution

永久性起搏器植入通常是通过上肢静脉完成的。但是，在1％-6％的情况下，由于上静脉腔（SVC）的完全阻塞或双侧下锁骨下静脉和/或双侧植入物感染或皮肤稀薄，因此通常不可能或禁忌锁骨接近。有必要采用替代方法，包括无铅的起搏器或复杂的铅提取技术，然后将手术性心外膜铅放置作为最后的手段，因为它具有自己的危害。我们报告了一名患有完全心脏阻塞的患者，以及先前植入的心外膜铅，与起搏器生命的末端呈现。鉴于手术选择的精疲力尽以及铅提取或无铅起搏器的资源限制情况，经过跨性心脏心脏起搏器植入并避免了重复手术。

Learning objective: Complete venous occlusion is not very often encountered after pacemaker/ICD implantation. Apart from the risk of general anesthesia and invasive surgery, epicardial leads increase battery drain, and have a shorter operating life compared to an endocardial lead. The sparingly utilized iliac venous approach for permanent pacemaker implantation is a valuable, safe and minimally invasive alternative, when the conventional percutaneous access is unavailable, and surgery is undesirable or not possible.

Occlusion of SVC or bilateral subclavian veins and bilateral pectoral site infection precludes use of conventional route of permanent pacemaker/ICD insertion. Anterograde and retrograde techniques to restore subclavian/SVC patency has been described [2]. Unconventional vascular access options include more proximal access of subclavian veins, internal jugular veins, external jugular veins, femoral and iliac veins and direct inferior vena cava route; to be tried according to site of obstruction [2].

We hereby report a post-permanent-pacemaker patient with total SVC obstruction and a previously implanted malfunctioning epicardial lead, presenting with complete heart block due to pacemaker end of life. Transiliac endocardial pacemaker implantation averted a repeat major surgery.

A 49-year-old gentleman was admitted to our hospital with episodes of presyncope/syncope due to complete heart block in 2010. He underwent a DDDR (REDR01-RELIA, Medtronic, USA) pacemaker implantation via right subclavian route uneventfully. In 2015, his symptoms recurred due to ventricular undersensing and non-capture by insulation failure of ventricular (RV) lead. Lead replacement was planned, but to our dismay, SVC was found completely occluded (Figure 1A,C). Percutaneous recanalization of SVC and lead extraction via femoral route failed, as wire always ended up in false lumen (Figure 1D) and dense fibrosis prevented lead mobilization. In another sitting, recanalization was attempted by transseptal puncture needle via left subclavian route, but was abandoned due to a small self-contained SVC perforation (Figures 1E,F). Finally, he underwent surgical epicardial RV lead placement and pulse generator was implanted in left subpectoral region.

经过2年的跨度，他由于铅故障（高阻抗，高阈值）而再次出现了晕厥。设备输出增加（脉冲宽度为1.0 ms的5.0伏）导致持续的隔膜刺激和过早的电池引流。

由于其他选项的耗尽，因此有必要进行替代访问选项。因此，考虑了通过右外静脉（EIV）进行的起搏器植入。在无菌条件和局部麻醉下，通过刺穿右股静脉，将导丝放置在正确的普通静脉中。借助荧光镜引导，右EIV在切开切口并剖析到筋膜平面后，在腹股沟韧带中部4厘米处刺穿4厘米，并用16口径的针小心避免动脉穿刺（图2）。使用16厘米的剥离鞘，在达到令人满意的起搏器参数后，将长RV活动固定引线（铅5076，85 cm，Medtronic）拧入RV顶点。在右心房中制作α环以降低脱位风险（图3）。在穿刺部位周围进行了倒置的L形解剖分，并在穿刺点双铅固定在外部斜筋膜上，并在使用附加的缝合套筒上进行掉落后，在掉头后（图2，示意图）。然后将铅铅沿着沿斜肌外部右腰部区域的单独切口形成的起搏器袋中隧穿。还将VVIR（RESR01-RELIA，MEDTRONIC）脉冲发生器固定在潜在的筋膜和皮下组织中，以防止重力下垂。最后，将组织和皮肤分层缝合，并进行压力敷料。 Operating time was 78 minutes. Abdomino-thoracic radiograph showing final position of old leads and new implant is seen in figure 4.

Patient was ambulated on 2^ndpostoperative day and discharged after 5 days on oral anticoagulation to prevent DVT. He was completely asymptomatic, lead parameters were satisfactory and no local implantation site-related issues were noted, at follow-up visit after 6 months. Six-monthly follow-up in pacemaker clinic is planned.

在起搏器植入后5％-12％的患者和ICD植入后的患者3％-18％的患者中，完全静脉阻塞已有报道[3]。尽管这些患者中不到10％是有症状的，因为抵押是足够的，但完全阻塞会导致铅修订或设备交换过程中的问题[3]。绕过这种并发症的各种策略包括铅提取和重新定性，内而外（逆行）重新定性，静脉成形术，手术旁路和新颖的无铅起搏器[4]。

In our patient, we meticulously tried to extract the leads and to recanalize SVC via Brokenborough/Mullins trans-septal puncture system in 2015, but failed. Perhaps long-standing fibrotic occlusion prevented success of all attempts and patient had to undergo epicardial lead placement. Apart from the risk of general anesthesia and more invasive surgery, epicardial leads increase battery drain due to higher thresholds and have shorter operating life (compared to endocardial lead) [5]. They have a higher rate of lead fracture due to tunneling between or beneath ribs to subcutaneous pocket [5]. Failure of even the ‘bail-out’ epicardial lead only within 2 years mandated alternative management strategy.

Ilio-femoral access for permanent pacing was first described by El Gamal and Van Gelder almost 40 years ago [6]. Femoral vein [7], iliac vein [1,8] and direct inferior vena cava [9], approaches have since been used for lead placement in cases of SVC occlusion. Supra-inguinal lead position via iliac vein access is probably safer in Indian subcontinent where prevalent social customs include repeated squatting. Pacemaker site infection, thrombophlebitis, thromboembolism, lead/generator erosion and surprisingly, even lead fractures are relatively rare complications in iliofemoral approach, reported in less than 1% [8,9]. Lead dislodgement is the major problem in infradiaphragmatic implantation with atrial dislodgement rates up to 21% and ventricular up to 7% [8,9]. Active fixation leads and creation of extra loop in atria probably decreases this risk. We chose ventricle-only pacing for this patient to minimize risk of dislodgement and unplanned re-procedures.

Leadless pacemaker would have been an ideal choice for this patient but was not possible for financial reasons as the patient didn’t have any medical insurance cover for his treatment and the cost was prohibitive for him. Dedicated lead extraction procedures and implanting newer leads through the same passage of extraction would have been another option in non-resource constrained situation and in centers having adequate expertise in the procedure.

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