Management of Venous Occlusion: Tunneling, Venoplasty and Other Tricks

October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

Management of Venous Management of Venous Occlusion: Tunneling, Occlusion: Tunneling,

Venoplasty and Other TricksVenoplasty and Other Tricks

Seth J. Worley MD FHRS FACCSeth J. Worley MD FHRS FACCThe Heart CenterThe Heart Center

Lancaster General HospitalLancaster General Hospital


Disclosures Disclosures

• I receive compensation in various forms I receive compensation in various forms from St Jude, Medtronic, Boston Scientific, from St Jude, Medtronic, Boston Scientific, Pressure Products, Biosense and OscorPressure Products, Biosense and Oscor


What would you do if you saw this What would you do if you saw this venogram? venogram?

1.1. Go to the other sideGo to the other side2.2. Extract one of the Extract one of the

leads for accessleads for access3.3. Try to get a wire Try to get a wire

across and use across and use progressively larger progressively larger dilatorsdilators

4.4. Try to get a wire Try to get a wire across and do across and do venoplastyvenoplasty


Subclavian Venoplasty for Subclavian Venoplasty for Pacemaker and ICD ImplantationPacemaker and ICD Implantation

• 10-30% with prior leads10-30% with prior leads have subclavian vein have subclavian vein stenosis/occlusionstenosis/occlusion

• We implant more frequently in patients We implant more frequently in patients with prior leadswith prior leads

• CRT – requires unrestricted catheter and CRT – requires unrestricted catheter and lead manipulationlead manipulation


Venoplasty vs. Progressively Venoplasty vs. Progressively Larger DilatorsLarger Dilators

• Venoplasty is faster Venoplasty is faster

• Problems with dilatorsProblems with dilators– catheters remain difficult to manipulate catheters remain difficult to manipulate

throughout the procedure. throughout the procedure. – distal stenosis (SVC/RA junction) is not distal stenosis (SVC/RA junction) is not

openedopened


Complications - Progressively Complications - Progressively Larger DilatorsLarger Dilators


Our Experience with Subclavian Our Experience with Subclavian VenoplastyVenoplasty

• Began subclavian venoplasty in 1999. Began subclavian venoplasty in 1999. • 370 cases as of October 2010370 cases as of October 2010• 8 EP physicians trained 8 EP physicians trained • No adverse clinical outcomeNo adverse clinical outcome

– No distal embolization - chronic occlusion no No distal embolization - chronic occlusion no thrombus thrombus

– No venous disruption – veins heavily encased No venous disruption – veins heavily encased in scar tissuein scar tissue

– No damage to the leadsNo damage to the leads


Basic System for Wire Resistant Basic System for Wire Resistant Subclavian Obstruction Subclavian Obstruction


Local Venogram to Cross the Local Venogram to Cross the OcclusionOcclusion


Range of Subclavian ObstructionRange of Subclavian Obstruction

• Moderate to severe – wire readily crosses Moderate to severe – wire readily crosses the obstruction the obstruction

• Apparent total (wire resistant) – requires Apparent total (wire resistant) – requires wire manipulation. wire manipulation.

• Total (wire refractory) – unable to get a Total (wire refractory) – unable to get a wire across.wire across.


Wires and Devices Used to “Cross” Wires and Devices Used to “Cross” Obstruction or OcclusionObstruction or Occlusion

• .035 Terumo Glidewire (angled with a .035 Terumo Glidewire (angled with a torque device)torque device)

• .018 glide wire (angled with a torque .018 glide wire (angled with a torque device)device)

• .014 angioplasty wires designed to cross .014 angioplasty wires designed to cross total occlusions total occlusions – Terumo CrosswireTerumo Crosswire– Cross-IT XT (100, 200, 300 in order of Cross-IT XT (100, 200, 300 in order of

stiffness)stiffness)


using the 5 F dilator and glide wire using the 5 F dilator and glide wire to Cross the Occlusionto Cross the Occlusion


System for Crossing Difficult System for Crossing Difficult OcclusionsOcclusions

Vert to Direct Wire PeripheralVert to Direct Wire Peripheral


Vert to Direct Wire CentralVert to Direct Wire Central


Vert to Cross TotalVert to Cross Total



Total Occlusion – Unable to Total Occlusion – Unable to get a wire acrossget a wire across

Wire Under Insulation and Extraction Wire Under Insulation and Extraction for Venous Access for Venous Access



Extraction & Wire Under Extraction & Wire Under InsulationInsulation

Wire Under the InsulationWire Under the Insulation



Total Occlusion Unable to Cross Total Occlusion Unable to Cross with a Wirewith a Wire


Laser Case - need venogram Laser Case - need venogram from the femoral vein to better from the femoral vein to better

define proximal lumendefine proximal lumen


Laser Case Laser Case Need to keep tip directed along Need to keep tip directed along

leads must be confirmed in leads must be confirmed in orthogonal viewsorthogonal views


Total No Lead LaserTotal No Lead Laser


Overall Success With Wire Overall Success With Wire Refractory Subclavian OcclusionRefractory Subclavian Occlusion

• Frontrunner alone 50%Frontrunner alone 50%

• Addition of Outback to Frontrunner 65%Addition of Outback to Frontrunner 65%

• Tornus 50% limited experienceTornus 50% limited experience

• Laser Wire 14 of 16 so farLaser Wire 14 of 16 so far


Balloons for Subclavian VenoplastyBalloons for Subclavian Venoplasty

• .035 inch central lumen – usually get a .035 inch central lumen – usually get a glidewire across the obstruction.glidewire across the obstruction.

• Preferred size, 6 mm X 4 cmPreferred size, 6 mm X 4 cm

• Preferred type, non compliant (rated burst Preferred type, non compliant (rated burst = 15 atm) = 15 atm) ((e.g. PowerFlex-P3e.g. PowerFlex-P3))

• Ultra non compliant Kevlar balloon if the Ultra non compliant Kevlar balloon if the waist is not relieved (rated burst = 30 atm) waist is not relieved (rated burst = 30 atm) (e.g. Conquest)(e.g. Conquest)


Always start “distally” - profile of the balloon Always start “distally” - profile of the balloon increases after the first inflation called increases after the first inflation called

“Winging”“Winging”


Complications - Progressively Complications - Progressively Larger DilatorsLarger Dilators


To prevent complications - To prevent complications - alwaysalways advance the glide wire advance the glide wire

into the PA before you inflate the into the PA before you inflate the balloon (or use progressively balloon (or use progressively

larger dilators) Videolarger dilators) Video


required Kevlar balloonrequired Kevlar balloon


Distal Obstruction OnlyDistal Obstruction Only


Focused Force Venoplasty for a Focused Force Venoplasty for a Focal Stenosis Refractory to KevlarFocal Stenosis Refractory to Kevlar


Focused Force VenoplastyFocused Force VenoplastyRequired for Diffuse Narrowing Following Required for Diffuse Narrowing Following

Removal of an Over the Wire LV LeadRemoval of an Over the Wire LV Lead


Balloon ExplodesBalloon Explodes


Surgical LV Lead Placement at UVASurgical LV Lead Placement at UVA

Ailawadi et al, Heart Rhythm 2010;7:619-625Ailawadi et al, Heart Rhythm 2010;7:619-625,,


30 Day MortalityTransvenous = 2.5%Surgical = 4.8%

Surgical LV Lead Placement UVA Charlottesville Surgical LV Lead Placement UVA Charlottesville Post Procedure ComplicationsPost Procedure Complications

• Acute renal injury = 26.2% surgical vs. Acute renal injury = 26.2% surgical vs. 4.9% transvenous (4.9% transvenous (P .001) P .001)

• Infection = 11.9% surgical vs. 2.4% Infection = 11.9% surgical vs. 2.4% transvenous (P .03)transvenous (P .03)

• 30 day mortality via thoracotomy = 7.1%30 day mortality via thoracotomy = 7.1%

• 30 Day Mortality = 2.5% transvenous vs. 30 Day Mortality = 2.5% transvenous vs. 4.7% surgical4.7% surgical


Ailawadi G et al Heart Rhythm 2010;7:619–625

REPLACE RegistryREPLACE Registry

• Thus 435 patients had an LV lead related Thus 435 patients had an LV lead related procedure (add or replace a lead)procedure (add or replace a lead)– 89% success thus 47 patients had failed LV lead 89% success thus 47 patients had failed LV lead

placementplacement– 4 deaths occurred at the time of surgical LV lead 4 deaths occurred at the time of surgical LV lead

placementplacement

• 8.5% (4/47) surgical mortality if all 47 went for 8.5% (4/47) surgical mortality if all 47 went for a surgical leada surgical lead


Total Occlusion No Leads to Total Occlusion No Leads to Extract or FollowExtract or Follow




Why Learn Venoplasty Why Learn Venoplasty Techniques?Techniques?

• Occlusions are usually not clinically apparentOcclusions are usually not clinically apparent• Not practical to obtain an interventional consult Not practical to obtain an interventional consult

in the middle of the casein the middle of the case• Reduces case time.Reduces case time.• Reduces the need to Implant on the opposite Reduces the need to Implant on the opposite

side or perform laser lead extractionside or perform laser lead extraction

If you don’t do venoplasty it will likely not get doneIf you don’t do venoplasty it will likely not get done


The EndThe End

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Management of Venous Occlusion: Tunneling, Venoplasty and Other Tricks

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