Venoplasty of the Innominate Vein-Superior Vena Cava Junction in a Patient with a PLSVC: The Path of Least Resistance is Sometimes Not the Easiest

CASE SUMMARY

A 74-year-old male with coronary artery disease and complete heart block presented to the electrophysiology laboratory for upgrade of a dual chamber pacemaker to a biventricular ICD. His pacemaker was implanted 22 months prior to his presentation. His left ventricular function had deteriorated to an ejection fraction of 30%, and he developed worsening heart failure with symptomatology consistent with NYHA Class III heart failure.

After removal of the existing pulse generator, access was obtained via an axillary approach. However, an .035 J-tipped guide wire could not be advanced past the superior vena cava (SVC). The J-tipped guide wire was exchanged for an .035 Wholey guide wire, which was advanced to the inferior vena cava (IVC). A second access was attempted, also with an axillary approach, but the guide wire was not able to be advanced past the innominate vein-SVC junction. A venogram, performed through a 4 Fr sheath in the axillary vein, revealed a persistent left superior vena cava (PLSVC) and a high-grade stenosis of the innominate-right SVC junction (Figure 1A).

 Venoplasty of the stenosis was then performed with 3 two-minute inflations at 4 atms using a 6 mm x 2 cm compliant balloon (Cordis POWERFLEX^® Pro) (Figure 1B). Post-venoplasty venogram revealed improved patency, and a second guide wire was easily advanced to the IVC (Figure 1C).

After placement of an ICD lead in the right ventricular apex, cannulation of the coronary sinus (CS) was performed using a 135º guide sheath (St. Jude Medical CPS Universal). Contrast injection through the sheath demonstrated a normal size CS and a “Y” shaped confluence of the PLSVC into the CS body (Figure 2). 

A balloon-occlusion venogram was then performed, revealing a posterolateral branch just distal to the PLSVC-CS junction (Figure 3A). The target vessel was selectively cannulated with a Worley “Vert” catheter (Pressure Products O.D. Target Vein Selector) through an inner catheter (St. Jude Medical SUB-ACU). However, despite having sub-selected the vessel with the inner catheter and an .014 guide wire (Abbott Vascular HI-TORQUE Whisper) placed in the distal segment of the vessel, the CS lead (St. Jude Medical 1458Q Quartet, 75 cm) could not be advanced (Figure 3B). Therefore, an alternative approach was taken through the middle cardiac vein (MCV). The guide sheath was withdrawn to the os of the MCV and then advanced into the vessel over an .035 wire. Placement of a CS lead into the posterolateral branch was successfully performed with the distal tip of the lead placed into the main CS body as an anchor (Figure 3C). Testing performed through the pulse generator from the two middle electrodes indicated excellent sensing and pacing thresholds. The remainder of the case was uneventful, including successful defibrillation threshold testing. Final fluoroscopy revealed excellent separation from the ventricular leads and lateral placement of the CS lead (Figure 4).

DISCUSSION

Cardiac device implantations (CDI) are common procedures performed in the electrophysiology laboratory. As more and more implants are being performed, obstacles and anatomic variations may be encountered that make a routine case challenging. This case demonstrates two of these potential challenges: (1) venous stenosis with chronic leads, and (2) a persistent left superior vena cava.

Venous stenosis is a known complication of CDI and is usually discovered at the time of system revision or upgrade. Epicardial lead placement, tunneled leads, and entire new system implants on the contralateral side of the stenosis are potential options, though far from ideal. A more appealing technique is venoplasty, which has well been described as a safe, low-risk technique for achieving access in those patients with venous stenosis.¹

A PLSVC occurs in approximately 0.3% of the population. A right SVC is also present in the vast majority of cases (90%), but a PLSVC can occur in isolation or with other anatomic variants. A PLSVC usually causes no symptoms and is often found incidentally when venous access is attempted for cardiac procedures, such as in this case. CDIs via PLSVC have been well reported.^2-5 However, there can be technical challenges in applying this technique. Also, arrhythmias, cardiogenic shock, tamponade, and CS thrombosis are potential complications of catheter manipulation through a PLSVC.⁶ The anatomic variations and acute angles encountered can make lead placement challenging. The CS is commonly dilated, compounding the difficulty of CS lead placement. In our case, the CS was relatively normal in size. We suspect that flow had been preferentially to the right SVC until the venous stenosis. When the stenosis occurred, flow was directed through the PLSVC into the CS. Since the higher flow to the CS was not a longstanding chronic condition, the CS was not dilated at the time of the procedure. 

Because of these technical challenges posed with lead placement through a PLSVC, we opted for a more traditional approach. Venoplasty of the stenosis provided us that option. This especially pertained to the CS lead given the location and angle of its takeoff from the CS. Even with direct cannulation of the branch from the main CS body, we were not able to place a lead. Fortunately, an alternative route was available through the MCV. This approach would not have been feasible if taken through the PLSVC, because of the multiple acute angles that the lead would have to negotiate. 

It is also important to comment on the position of the CS lead (Figure 4). The lead used is a newer generation lead with four pacing electrodes (quadripolar), compared to the older generation leads which have only one (unipolar) or two electrodes (bipolar). The tip with the distal electrode (D1) was positioned in the main CS body and used to anchor the lead in position. Pacing was performed from the middle two electrodes (M3, M2) that were at a mid-basal segment of the lateral left ventricle, which has been shown to be the optimal site for improved outcomes and acute hemodynamic response with biventricular pacing.^7-9

Vascular anomalies, whether iatrogenic or congenital, are not infrequent challenges that an implanting physician may encounter. Techniques to overcome these challenges are well described. The implanting physician must be able to recognize these anomalies and apply the appropriate techniques for the situation. Additionally, a well-equipped lab and staff trained in electrophysiologic and interventional procedures working with the implanting physician will ensure the highest chance of success with minimal risk to the patient.

Disclosures: Dr. Woo, Dr. Tamberella, and Ms. Morrow have no conflicts of interest to report. Mr. Turek and Mr. Decker report employment and stock with St. Jude Medical. 

References

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