M y S uggestedA lgorithm :InterventionalApproachinaP atientW ithCardiovascularIm plantableElectronicDevice

T heodoreF.S aad,M .D.

N ephrology Associates,P .A.

Chief,S ectionofR enal&HypertensiveDisease

ChristianaCareHealthS ystem ,N ew ark,Delaw are

w w w.delaw arekidney.com

tsaad@ delaw arekidney.com

Disclosures

• CR BardP eripheralVascular

• CR BardAccess

• W L Gore

• Hum acyte

N onerelevanttothispresentation

Definitions

• P erm anentP acem aker(P P M )

• Im plantablecardioverter-defibrillator(ICD)

• Cardiovascularim plantableelectronicdevice(CIED)

• P P M

• ICD

• T ransvenousversusalternativepathw ay

AlternativeDevices

S ubcutaneousDefibrillator L eadlessP acem akerEpicardialP acem aker

Algorithm sforCIED:InterventionalApproach& P atientM anagem ent

HA S CIED w ithT ransvenousL eads

• N otonHem odialysis• ElectiveCKD-4-5

• N eedsAV access

• U rgentorIm m ediate• AV Accessvs.Catheter

• O nHem odialysis• IpsilateralAV A ccess

• ContralateralAV Access

• VenousCatheter

N EEDS CIED

• Indications• P P M

• ICD:P rim ary vs.S econdary

• CKD notondialysis

• ES R D onHem odialysis

S aadT F,HentschelD,KoplanB,W asseH,AsifA,P atelDV,S alm anL ,CarrilloR ,HoggardJ: CardiovascularIm plantableElectronicDeviceL eadsinChronicKidney DiseaseandEnd-S tageR enalDiseaseP atients:R eview andR ecom m endationsforP ractice.S em inarsinDialysis2012;26:114-123.http://w w w .ncbi.nlm .nih.gov/pubm ed/22891983

Case-1

Case-1T ools

Case-1

Case-1

Case-1

Case-1:CIED-AssociatedCV O cclusion

T ools

• Im agingcatheter

• Guidingcatheter• Directionalcontrol• Backbone

• Hydrophilicw ire• S traight• S tiff• Back-end

• N O T :S harp,“ inside-out,” orradiofrequency ablation

T echnique

• P atient:T akestim e

• P ersistent:Don’tgiveupeasily

• P robe:Findopening

• P ush:Gentlebutfirm ;stiffness

• P athw ay:S om etim esfrom below

• P articipation:Anothersetofhands

• P ullout:Know w hentostop

• P T A:Biggernotalw aysbetter

• P lan:W hathappensnext?

• P leasure:M ostgratifying procedure

Case-2

• 2006:L eftsubclavianICD placedforVT arrestafterM I• “ S econdary prevention”

• 2010:L eftupper-arm (ipsilateral)cephalicfistulacreated

• 2010-2014:R equired10 peripheral interventions• O nethrom bectom y

• Cephalicarchstent-graft

• Accessflow 500-1500 m l/m in

• N osym ptom aticvenoushypertension

• NO central veinangioplasty

S aadT F,Ahm edW ,DavisK,Jurkow itzC:CardiovascularIm plantableElectronicDevicesinHem odialysisP atients:P revalenceandIm plicationsforArteriovenousHem odialysisAccessInterventions.S em inarsinDialysis2015;28:94-100.http://w w w.ncbi.nlm .nih.gov/pubm ed/24863543

2013

• Functionalfistula• M inim alL -S CL stenosis• N osw elling

Case-2:2014 L U Esw ellingw ithL -S CL stenosis

• 2014: P T A x 1 (12 m m )

• 2015: P T A x 2 (12 & 14 m m )

• 2016: P T A x 3 (14 m m )• 3-m onthintervals

• Incom plete,transientresponse

2015

2015

• L eftS CL stenosis• P T A 14 m m

2015

Case-2:O ptions

• L eaveCIED & AVF“ as-is” andcontinuefrequentrepeatedangioplasty

• L eaveCIED & createnew contralateralAV access

• L eaveAV access,rem oveCIED lead• Continued indicationforCIED? Donotreplaceifnotindicated

• S tentS CL vein,replacew ithnew leadviastent

• R eplaceCIED oncontralateralside

• Im plantsubcutaneousdefibrillatororleadlessP P M

• P erform flow -reduction“ banding” procedure

• S tentw ithCIED leadsinplace

L eadExtractionw ithIpsilateralAV Access• R isk:M ortality 0.28-0.8% ingeneralpopulation

• L ikely higherinES R D patients

• Highflow,highpressurevenousblood

• Venousinjury from laserleadextraction

• Atourhospital2 ES R D patientshavediedduringattem ptedelectiveleadextractionduetouncontrolledhem orrhage

• O urEP labstandard:• P repforpossiblethoracotom y

• CT surgery on“ stand-by”

ByrdCL ,W ilkoffBL ,L oveCJ,S ellersT D,R eiserC:ClinicalS tudy ofthelasersheathforleadextraction:T hetotalexperienceintheU nitedS tates.JP acingClinElectrophysiology 2002;25:804-808 https://w w w .ncbi.nlm .nih.gov/pubm ed/12049372W azniO ,EpsteinL M ,CarilloR G,etal.:L eadextractioninthecontem porary setting:T heL ExIConS tudy.JAm CollCardiol2010;55:579-586 https://w w w .ncbi.nlm .nih.gov/pubm ed/20152562

Case2:

• Cardiacsituation• Im proved LV function,EF=40%

• N odevicedischargesinceim plantationin2009

• L eadrecalled,needsreplacem ent

• DecisiontoexplantentireICD andnotreplace

• AVFaccessed• 12 Frenchsheath• Am platzw irethroughL -S CL stenosisintoIVC• Angioplasty L -S CL veinstenosis

Com binedEP Cardiology &InterventionalN ephrology P rocedure

• O ccludecephalicarchw ithballoon• Keepfistulafilled w ithsalinetoavoid throm bosis• Explantpulse-generator• L aserleadextraction

• R em oveICD lead• R epeatL -S CL veinP T A• R eleaseocclusionballoon

P ostL eadExtraction

• 5 m onthfollow up

• N orecurrentsw elling

• N ore-intervention

S tentingO verCIED L eads

CO N S

• Discouraged(not“ forbidden” )by• AHA-HR S Guidelines*

• AS DIN W orkgroup

• P otentialproblem sifleadextractionrequiredinfuture

• N o(?)publishedreportsofcom plicationsrelatedtostententrappedleads

P R O S

• Im m ediate,inexpensive,andaseffectiveasany CV stent

• P rotectsCV patency indifficulttocrossocclusion

• N otproventobeunsafe

• Avoidaccesssurgery &/orleadextractionrisks,m orbidity,cost

• L eadextractionrem ainspossibleinsom ecases

* W ilkoffBL ,L oveCJ,ByrdCL ,BongiorniM G,CarrilloR G,Crossley GH 3rd,EpsteinL M ,Friedm anR A,KennergrenCE,M itkow skiP ,S chaerfR H,W azniO M :T ransvenousleadextraction:HeartR hythm S ociety expertconsensusonfacilities,training,indications,andpatientm anagem ent.HeartR hythm 2009;6:1085-1104.https://w w w .ncbi.nlm .nih.gov/pubm ed/19560098

S tentingO verCIED L eads• R arely w arranted

• GoodEP support

• Carefulvascularaccessplanning

• Alternativesolutions

• O urpractice:• 2005-2009:14 cases

• 2009-present:2 cases

• Consideronly w hen:• S im pleP T A clearly failed

• S everesym ptom aticsw elling

• Highquality AV access

• L im itedlife-expectancy duetoage,m ajorcom orbidities

• P ooropportunity fornew AV access

• Highriskforleadextraction

• P atientfully inform ed

• Cardiologistaw are.agrees

S aadT F,M yersGR ,CiconeJS :Centralveinstenosisorocclusionassociatedw ithcardiacrhythm m anagem entdeviceleadsinhem odialysispatientsw ithipsilateralarteriovenousaccess:A retrospectivestudy oftreatm entusingstentsorstent-grafts.JournalofVascularAccess2010;11:293-302.http://w w w .ncbi.nlm .nih.gov/pubm ed/20658455

Case3

• 80 yearoldw om anonHD• P rostheticm echanicalM V• L -P P M

• June2016 FailedAVF• P lacedT DC

• August2016• Creatednew R U A basilictranspositionAVF• S low tom ature

• Jan2017• S taphepiderm idissepsis,adm itted,T DC rem oved• Bloodculturescleared,w ithoutCIED leadrem oval• T EE:L argeM V vegetation,W BC 40K… … ?• N otcandidateforre-doM V surgery

DidsheneedT DC? W hatw erealternatives?Early-stickgraft?P eritonealdialysis?

W hy didittake2-m onthstocreatenew AVF?W asaBVT thebestchoice?

W hatw asdonetoenhancem aturation?Couldthishavebeenusedsoonerthan4 m onths?

S hem ay diefrom this

VenousCatheters& T ransvenousCIED L eads:A T oxicCom bination1. P atientsutilizingT DC forhem odialysisaccessshouldnotundergotransvenousCIED lead

im plantationuntilperm anentdialysisaccessisestablished andthevenouscatheterrem oved

2. T herationaleforICD im plantationasprim ary-preventionshouldbecarefully consideredforCKD/ES R D patients

3. P atientsw ithexistingtransvenousCIED leadsshouldnotundergovenoushem odialysiscatheterplacem entunlessthereisnootherreasonablealternativeform anagingCKD/ES R D.

4. P atientsforw hom com binedT DC andCIED w ithtransvenousleadscannotbeavoidedshouldbeactively m anagedtom inim izetherisksforbacterem ia

5. P atientsw ithadvancedCKD orES R D w horequireperm anentpacingshouldbeconsideredforaleadlesspacingsystem ;w henundergoingcardiacsurgery,epicardialleadsshouldbeconsidered

• AsifA,S alm anL ,L operaG,HaqqieS S ,CarrilloR :T ransvenouscardiacim plantableelectronicdevicesandhem odialysiscatheters:R ecom m endationstocurtailapotentially lethalcom bination.S em inDial2012;25:582-6.https://w w w .ncbi.nlm .nih.gov/pubm ed/22353033

• S aadT F,W einerH:VenousHem odialysisCathetersandCardiacIm plantableElectronicDevices:AvoidingaHigh-R iskCom bination.S em inarsinDialysis2017;accepted,pendingpublication