Original Article
Spontaneous subclavian venous occlusion before electronic device implantation
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 530–534 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314567925 aan.sagepub.com
Takeshi Kodani, Takanao Mine, Hideyuki Kishima, Kenki Ashida and Tohru Masuyama
Abstract Background: Subclavian venous occlusion sometimes precludes the ability to insert leads during placement of a cardiac implantable electronic device. This study was performed to identify the risk factors for spontaneous subclavian venous occlusion prior to placement of an implantable electronic device. Methods: We studied 446 patients who underwent axillary-subclavian venography to assess for occlusion and/or anomaly of the subclavian vein or associated veins before electronic device implantation. Results: Six (1.3%) patients had venous occlusion (left subclavian vein in 5, left innominate vein in 1). There was a significantly higher incidence of previous cancer in the occlusion group than in the nonocclusion group (11.5% vs. 50%, p ¼ 0.03). Conclusions: Subclavian venous occlusion may be present before cardiac implantable electronic device placement. A history of cancer represents a risk factor subclavian venous occlusion, and patients with this risk factor should undergo subclavian venography prior to electronic device placement.
Keywords Defibrillators, implantable, Neoplasms, Pacemaker, artificial, Subclavian vein, Venous thrombosis
Introduction The subclavian vein is usually employed for insertion of pacemaker leads and implantable cardioverter defibrillator leads in patients undergoing placement of a cardiac implantable electronic device (CIED).1,2 However, venous obstruction or an anatomic anomaly can sometimes complicate lead insertion.3,4 In the 11th World Survey of Cardiac Pacing and Implantable Cardioverter-Defibrillators, all countries reported increases in the number of pacemakers and implantable cardioverter defibrillators implanted over the 4 years between surveys.5 Furthermore, among patients with mild heart failure (New York Heart Association class II), cardiac resynchronization therapy reduces mortality and the risk of heart failure events.6 The use of cardiac resynchronization devices has been increasing because of expanded indications for their use. Therefore, the opportunity to encounter situations of venous occlusion or anatomic anomaly has increased. For the patient with relevant venous occlusion, an alternative site of device implantation is chosen.
Oginosawa and colleagues7 reported that the incidence of asymptomatic venous obstruction before CIED placement was 4%. However, predictors of venous obstruction prior to CIED placement remain unclear. The aims of this study were to characterize the incidence of subclavian venous occlusions before CIED placement and to clarify the risk factors for vein obstruction before CIED placement.
Patients and methods The study included 446 patients (277 men; mean age, 71 12 years) who underwent subclavian venous Department of Internal Medicine, Cardiovascular Division, Hyogo College of Medicine, Nishinomiya, Japan Corresponding author: Takanao Mine, MD, Department of Internal Medicine, Cardiovascular Division, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan. Email: [email protected]
Downloaded from aan.sagepub.com by guest on November 19, 2015
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angiography before initial CIED placement at Hyogo College of Medicine between January 2006 and February 2014. The devices comprised 334 pacemakers, 70 implantable cardioverter defibrillators, and 42 cardiac resynchronization therapy devices). CIED placement was in the left anterior chest in 411 patients and the right anterior chest in 35. Right-sided implantation was used in patients who had a dialysis shunt in the left anterior forearm or a left subclavian venous occlusion or venous anomaly. Patients with renal dysfunction without the need for dialysis (n ¼ 23) and those with a history of contrast media allergy (n ¼ 1) were excluded from this study. Renal dysfunction was defined as an estimated glomerular filtration rate of 30 mL/min/ 1.73 m2 or less. Data of past medical history, physical examination, 12-lead electrocardiogram, and chest radiography on admission were recorded. The patients gave consent to undergo injection of contrast medium and angiographic imaging to check for an occlusion and/or anomaly of the vein. We injected 15 mL of contrast medium (iopamidol) into a vein in the forearm of the side of intended CIED placement. Angiographic imaging from the axillary vein to the superior vena cava was performed at a frame rate of 7.5 per second under fluoroscopy (Infinix Celeve-I, Toshiba Medical, Japan). The subclavian vein was defined as the vein from the outer edge of the first rib to the internal jugular vein junction portion, and the innominate vein was from the junction portion to the superior vena cava. We defined venous obstruction as total occluded of the vein contrasted through the collateral vessels during angiography. Venous anomaly included only persistent left superior vena cava
(PLSVC). The CIED was placed on the opposite side in patients with venous obstruction or PLSVC. Continuous variables are expressed as mean and standard deviation. Categorical variables are expressed as percentages. Statistical analyses were performed using the Mann-Whitney U test and the chi-square test (Fisher’s exact test) for comparisons between groups. A p value
Spontaneous subclavian venous occlusion before electronic device implantation
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 530–534 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314567925 aan.sagepub.com
Takeshi Kodani, Takanao Mine, Hideyuki Kishima, Kenki Ashida and Tohru Masuyama
Abstract Background: Subclavian venous occlusion sometimes precludes the ability to insert leads during placement of a cardiac implantable electronic device. This study was performed to identify the risk factors for spontaneous subclavian venous occlusion prior to placement of an implantable electronic device. Methods: We studied 446 patients who underwent axillary-subclavian venography to assess for occlusion and/or anomaly of the subclavian vein or associated veins before electronic device implantation. Results: Six (1.3%) patients had venous occlusion (left subclavian vein in 5, left innominate vein in 1). There was a significantly higher incidence of previous cancer in the occlusion group than in the nonocclusion group (11.5% vs. 50%, p ¼ 0.03). Conclusions: Subclavian venous occlusion may be present before cardiac implantable electronic device placement. A history of cancer represents a risk factor subclavian venous occlusion, and patients with this risk factor should undergo subclavian venography prior to electronic device placement.
Keywords Defibrillators, implantable, Neoplasms, Pacemaker, artificial, Subclavian vein, Venous thrombosis
Introduction The subclavian vein is usually employed for insertion of pacemaker leads and implantable cardioverter defibrillator leads in patients undergoing placement of a cardiac implantable electronic device (CIED).1,2 However, venous obstruction or an anatomic anomaly can sometimes complicate lead insertion.3,4 In the 11th World Survey of Cardiac Pacing and Implantable Cardioverter-Defibrillators, all countries reported increases in the number of pacemakers and implantable cardioverter defibrillators implanted over the 4 years between surveys.5 Furthermore, among patients with mild heart failure (New York Heart Association class II), cardiac resynchronization therapy reduces mortality and the risk of heart failure events.6 The use of cardiac resynchronization devices has been increasing because of expanded indications for their use. Therefore, the opportunity to encounter situations of venous occlusion or anatomic anomaly has increased. For the patient with relevant venous occlusion, an alternative site of device implantation is chosen.
Oginosawa and colleagues7 reported that the incidence of asymptomatic venous obstruction before CIED placement was 4%. However, predictors of venous obstruction prior to CIED placement remain unclear. The aims of this study were to characterize the incidence of subclavian venous occlusions before CIED placement and to clarify the risk factors for vein obstruction before CIED placement.
Patients and methods The study included 446 patients (277 men; mean age, 71 12 years) who underwent subclavian venous Department of Internal Medicine, Cardiovascular Division, Hyogo College of Medicine, Nishinomiya, Japan Corresponding author: Takanao Mine, MD, Department of Internal Medicine, Cardiovascular Division, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan. Email: [email protected]
Downloaded from aan.sagepub.com by guest on November 19, 2015
Kodani et al.
531
angiography before initial CIED placement at Hyogo College of Medicine between January 2006 and February 2014. The devices comprised 334 pacemakers, 70 implantable cardioverter defibrillators, and 42 cardiac resynchronization therapy devices). CIED placement was in the left anterior chest in 411 patients and the right anterior chest in 35. Right-sided implantation was used in patients who had a dialysis shunt in the left anterior forearm or a left subclavian venous occlusion or venous anomaly. Patients with renal dysfunction without the need for dialysis (n ¼ 23) and those with a history of contrast media allergy (n ¼ 1) were excluded from this study. Renal dysfunction was defined as an estimated glomerular filtration rate of 30 mL/min/ 1.73 m2 or less. Data of past medical history, physical examination, 12-lead electrocardiogram, and chest radiography on admission were recorded. The patients gave consent to undergo injection of contrast medium and angiographic imaging to check for an occlusion and/or anomaly of the vein. We injected 15 mL of contrast medium (iopamidol) into a vein in the forearm of the side of intended CIED placement. Angiographic imaging from the axillary vein to the superior vena cava was performed at a frame rate of 7.5 per second under fluoroscopy (Infinix Celeve-I, Toshiba Medical, Japan). The subclavian vein was defined as the vein from the outer edge of the first rib to the internal jugular vein junction portion, and the innominate vein was from the junction portion to the superior vena cava. We defined venous obstruction as total occluded of the vein contrasted through the collateral vessels during angiography. Venous anomaly included only persistent left superior vena cava
(PLSVC). The CIED was placed on the opposite side in patients with venous obstruction or PLSVC. Continuous variables are expressed as mean and standard deviation. Categorical variables are expressed as percentages. Statistical analyses were performed using the Mann-Whitney U test and the chi-square test (Fisher’s exact test) for comparisons between groups. A p value
