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