Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 66 years-old male presented with history of exertional breathlessness of NYHA Class III severity. He had past history of double valve replacement 17 years ago and history of two episodes of hospitalization due to left ventricular failure and was on optimal medical therapy.
Relevant test results prior to catheterization
ECG revealed sinus rhythm with complete LBBB with QRS duration of 160 msec duration.
On echocardiography, left ventricle and left atrium were dilated with global hypokinesia and poor left ventricular systolic function with ejection fraction of 20%.
Relevant catheterization findings
Coronaries were normal on diagnostic angiogram.
Left cephalic vein access was done to insert three guide wires. With the help of EP catheter and long sheath, coronary sinus was engaged. Left ventricular lead was successfully positioned in the anterolateral tributary. For insertion of right ventricular lead,it was not possible to negotiate sheath with dilator as well as dilator alone despite repeated attempts. Venogram revealed presence of partial subclavian vein occlusion. Hydrophilic terumo wire was used to cross the obstruction and was kept in inferior vena cava for support. But it was not possible to negotiate sheath across the vein. Terumo wire was exchanged with amplatz super stiff wire but all went in vain. Finally balloon dilation of subclavian vein was done with peripheral balloon mustang 6 x 60 at 8 atm pressure. Balloon dilation was done twice. Subsequent sheath and lead insertion were uneventful and the procedure was successfully completed without any complication.
The partial and complete occlusions of subclavian veins are commonly encountered in device implantation. Subclavian venoplasty is safe and effective method. Alternative approaches are implanting device on opposite side, direct puncture of innominate vein, passage of leads using collaterals from superior vena cava. These are cumbersome time consuming procedure. Subclavian venoplasty is safe with minimal complications related to balloon rupture and vein dissection.