Acta Cardiol 2013; 68(4): 449-451
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doi: 10.2143/AC.68.4.2988904
Permanent transvenous pacemaker implantation following percutaneous transluminal angioplasty in a patient with asymptomatic bilateral subclavian vein stenosis Özgür ÇIFTÇI1, MD; Murat GÜNDAY2, MD; Aytekin GÜVEN1, MD 1
Department of Cardiology; 2Departments of Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, Turkey.
Abstract Subclavian venous obstruction is a disorder that arises more frequently today, due to the increased frequency of vascular interventions. It may affect one or both of the subclavian veins. When bilateral, it complicates the implantation of several devices that are preferably installed via the upper-extremity veins. Among these are pacemakers, cardiac defibrillators, catheters for haemodialysis, and even port catheters. In this study, we present a patient with symptomatic Mobitz type II AV block, who was planned to undergo a pacemaker implantation. Previously the patient had undergone two coronary bypass operations. Probably due to the interventions made at that time, he was now diagnosed with bilateral subclavian vein obstruction. Following the diagnosis, the obstruction in the right subclavian vein was successfully relieved through balloon angioplasty, after which a permanent atrioventricular pacemaker was installed.
Keywords Bilateral – asymptomatic – pacemaker – obstruction – occlusion.
INTRODUCTION
CASE REPORT
In the presence of bilateral upper-extremity venous obstruction, it is very hard to install a transvenous pacemaker. In the literature, there is only a limited number of cases with unilateral subclavian vein stenosis which have undergone venoplasty or dilatation for the ultimate purpose of pacemaker implantation1,2. We did not encounter any patients who had undergone dilatation and pacemaker implantation following bilateral subclavian vein occlusion. A bilateral subclavian vein occlusion was detected in the present case, probably linked to previous intravascular interventions. The obstruction in the right subclavian vein was successfully relieved through balloon angioplasty, and a permanent atrioventricular pacemaker was installed.
The patient, an 85-year-old male, applied to our polyclinic with complaints like fainting spells, exhaustion following effort, and general fatigue. Medical history included additional cardiac risk factors like diabetes mellitus, hypertension and hyperlipidaemia. Furthermore, on account of coronary artery disease, the patient had undergone two bypass operations in 1998 and 2003. Blood pressure was 150/40 mmHg, and electrocardiography revealed Mobitz type II AV block as well as a heart rate of 40 beats per minute. The other parameters revealed by echocardiography were as follows: inferior, apical, hypokinetic septum, ejection fraction: 35%, mitral failure (first degree), and tricuspid failure (first degree). The patient was examined for coronary artery disease by coronary BT angiography. It was observed that his vein grafts were patent. Nevertheless, because of symptomatic bradycardia, it was decided to implant a permanent pacemaker. The patient was placed under local anaesthesia and a skin incision, running parallel to the clavicle, was made in the left prepectoral region. Using blunt dissection, a pocket was opened on the prepectoral fascia for the permanent pacemaker. But then it did not prove
Address for correspondence: Özgür Çiftçi, M.D., Department of Cardiology, Başkent University Konya Application and Research Hospital, Hocacihan Mah. Saray Cad. No: 1, 42080, Selçuklu, Konya, Turkey. E-mail:
[email protected] Received 18 December 2012; accepted for presentation 14 May 2013.
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A
B
Fig. 1 On angiography: A: the 80% occlusion in the right subclavian vein, B: total occlusion in the left vein.
possible to push the guidewire further, and accordingly it was decided to perform a venography. The left side venography that was first performed revealed a 100% occlusion in the conjunction of the left subclavian and brachiocephalic veins. Thereupon a right side venography was performed, which revealed an occlusion of 80% (figure 1a-b). For this reason, it was decided to perform angioplasty in order to relieve the stenosis in the right subclavian vein. Under local anaesthetics, the right subclavian vein was entered and a 7-F vascular sheath (Medtronic) was inserted. After this, the inferior venal
cava was reached by using a 5-F catheter and hydrophilic guidewire. Via the stiff guidewire, with a balloon of 10 × 40 mm diameter, dilatation was applied to the site of the stenosis (Boston Scientific) (figure 2). The control angiography images, produced after the intervention, revealed that the stenosis had been relieved at a ratio of 95%. Following this, the lead (MEDTRONIC 5038) was placed via the right subclavian vein on the right ventricular apex (figure 3). The pacemaker (Medtronic Relia REVDD01) was implanted into the pocket that had been prepared earlier. The patient was discharged after
Fig. 2 Following angioplasty, it is observed that the right subclavian vein is now patent.
Fig. 3 The pacemaker after implantation via the right subclavian vein.
Permanent transvenous pacemaker
prescribing antihypertensive and antiaggregant treatment (acetylsalicylic acid, 100 mg 1 × 1, telmisartan + hydrochlorothiazide, 80/12.5 mg 1 × 1). In the regular outpatient follow-up, no problems were observed in the patient and the pacemaker turned out to be working normally. The upper-extremity venous Doppler that was performed three months later revealed that the right subclavian vein was still patent.
CONCLUSION Subclavian vein stenosis is a complication that may arise after the installation of a pacemaker, a cardiac defibrillator or a catheter for haemodialysis. Bilateral primary subclavian vein occlusion is uncommon. In a study on venous occlusion in patients who were fitted with a transvenous pace lead, partial venous obstruction before the implantation of any device was found to be 13.7%, and total occlusion 6% 3. After the operation, however, it is possible for these ratios to rise to values as high as 60% or more4. Subclavian vein stenosis can be either uni- or bilateral. Because of the extensiveness of upper-extremity venous collaterals, it is generally asymptomatic. Nevertheless, it may also lead to oedema and swellings on the face, neck or breasts. In our case, there were no complaints linked to the subclavian vein stenoses. In the treatment of subclavian vein stenoses, either surgical or endovascular methods may be preferred. In the former case, a year after the jugular vein transposition or bypass, it was found that the vein was patent between 75 and 81% 5-7. However, surgical treatment cannot be applied to all patients. Especially in the case of elderly patients with poor general health or patients with heart or kidney failure, less invasive methods may be preferred. In
the literature, D.S. Bhatia et al. found out that the results of surgical treatment and balloon angioplasty were similar5. On the other hand, in their retrospective study on haemodialysis patients with central vein occlusion, Aytekin et al. found that the rates of primary stent patency in the first, third and sixth months were 92.8, 85.7 and 50%, respectively. On this basis, they concluded that repeated interventions are usually necessary to ensure stent patency in the long term8. Moreover, there are also publications indicating that endovascular interventions produce better results in terms of mortality and morbidity9. In conclusion, it can be pointed out that we have not encountered any previous cases in which a patient with bilateral subclavian vein stenosis was fitted with a permanent pacemaker. To our knowledge, our patient represents the first case in this respect. We believe that endovascular methods are both efficient and reliable whenever a permanent pacemaker or a catheter for external defibrillation has to be implanted in a patient who has bilateral subclavian vein obstruction. We are also convinced that in such cases the methods in question should be given preference over the others.
CONFLICT OF INTEREST None of the authors have any personal or financial relationships that have the potential to bias or otherwise exert an inappropriate influence on his or her views in the manuscript, and no financial or other potential conflicts of interest (including any involvement with organizations that have a direct financial, intellectual or other interest in the topic) exist regarding the manuscript. In addition, there are no grants or sources of financial support linked to the topic of the manuscript.
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