Author + information
Patient initials or identifier number
Mrs. Min 2841126
Relevant clinical history and physical exam
An 89 years-old female with hypertension and pulmonary fibrosis experienced palpitation off and on for 3 weeks. Bradycardia and hypotension developed by more beta-blocker, but soon resolved after temporary transvenous pacing.The sick sinus syndrome (paroxysmal Af and long pause 3.9 sec) were confirmed.
Permanent pacemaker (PPM) implantation was planned at other hospital. The Venography: Total occlusion of left in nominate and severe stenosis at right subclavian vein (SCV). The procedure failed due to R't Pneumothorax.
Relevant test results prior to catheterization
The right pneumothorax resolved soon after pigtail catheter drain, she was referred to our hospital for PPM implantation. Another antegrade venography via right radial vein showed subtotal occlusion of right SCV. PPM was deferred.
Surgical approach with epicardial lead and generator in the abdominal area was not favored because of high surgical risk. The retrograde approach to recanalize right SCV subtotal occlusion and balloon-assisted puncture for vein access were planned.
Relevant catheterization findings
The antegrade venography still showed subtotal occlusion of right SCV with collateral flow.
The retrograde venography showed patent right internal jugular vein.
The 7Fr multiple purpose GC via R't femoral vein access was advanced to right superior vena cava, near subtotal occlusion of SCV. Retrograde venography showed no retrograde flow to Right SCV, but patent internal jugular vein.
A 0.014” Fielder-Fc wire, loaded in 135 cm Corsair microcatheter (MC), was advanced retrogradely into subclavian vein. Antegrade venography showed possible subintimal tracking and wiring out of vessel.The wire in false lumen was withdrawn and advanced across tortuous collateral channel loop and slowly into proximal SCV. The gentle wire manipulation overcame the acute angle between collateral vessel and SCV Retrograde-wire gradually crossed SCV subtotal occlusion by antegrade manner and was further advanced into guiding catheter.The Corsair MC was also advanced into guiding catheter along wire. Rendezvous technique in GC failed (Another Fielder FC wire, loaded in 130 cm FineCross MC, failed to be advanced into Corsair MC).
Externalization completed by by RG-3 330 cm wire
FineCross MC crossed subtotal occlusion retrogradely along RG-3 wire
Fielder FC replaced RG-3 wire and was advanced into proximal SCV along Fine Cross MC
Balloon dilatation and IVUS at Right SCV subtotal occlusion were performed and vessel sizes were evaluated
The 3.0 x 20 mm Balloon was inflated in subtotal occlusion segment
By aiming balloon in SCV, puncture needle penetrated balloon and reached right SCV
Balloon-assisted puncture to access SCV and PPM lead insertion were successful.
The permanent pacemaker implantation is generally considered a minimally invasive procedure, but the complication during trans cutaneous central vein access might occurred, especially in elderly patients with technical difficulty due to deviated anatomy and subclavian vein stenosis, like this patient. Recanalization of Right subclavain vein subtotal occlusion was achieved by advancing wire retrogradely to proximal subclavian vein through collateral channel, then antegradely wiring across subtotal occlusion. After dilating subtotal occlusion and creating bigger channel, balloon-assisted puncture was succeeded to access subclavian vein and safely complete permanent pacemaker lead insertion.