Chronic venous obstruction during cardiac device revision: Incidence, predictors, and efficacy of percutaneous techniques to overcome the stenosis

BACKGROUND In recent years, upgrade and revision procedures of cardiac implantable electronic devices (CIEDs) have become increasingly frequent. Patency of the access veins is critical for procedural success. OBJECTIVE The purpose of this study was to determine the incidence of venous obstruction at the time of system revision, to identify predictors of venous stenosis, and to evaluate the efficacy and safety of percutaneous techniques for overcoming stenosis. METHODS All patients admitted to our division from January 2004 to January 2017 for CIED revision with the intent to add 1 or more leads were included. Each patient underwent ipsilateral contrast venography. The degree of venous stenosis was determined with the support of quantitative coronary angiography and categorized as significant (75 degrees/0-90%), subocclusive (90 degrees/0-99%), or occlusive (100%). RESULTS Of 227 patients, 61 (27%) showed a stenosis >75%. Different techniques were performed to overcome stenosis: direct vein access, distal venous puncture central to the stenosis, and percutaneous venoplasty in 25 (41%), 26 (43%) and 9 (15%) cases. respectively. All procedures were successful, without major complications. At multivariate analysis, having 3 leads before revision (odds ratio 0.444; 95% confidence interval 0.212-0.920; P = .029) and a previous system revision with lead insertion (odds ratio 0.323; 95% confidence interval 0.124-0.841; P = .021) were independent predictors of venous stenosis. CONCLUSION Chronic venous obstruction is a relatively frequent finding after CIED implantation. The number of implanted leads seems to be an independent predictor of venous obstruction. In case of stenosis, the preprocedural a ngiography-guided structured approach allowed preservation of both contralateral access and functioning leads.