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Management of Venous Occlusion: Tunneling, Venoplasty and Other Tricks

Management of Venous Occlusion: Tunneling, Venoplasty and Other Tricks. Seth J. Worley MD FHRS FACC The Heart Center Lancaster General Hospital. Disclosures. I receive compensation in various forms from St Jude, Medtronic, Boston Scientific, Pressure Products, Biosense and Oscor.

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Management of Venous Occlusion: Tunneling, Venoplasty and Other Tricks

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  1. Management of Venous Occlusion: Tunneling, Venoplasty and Other Tricks Seth J. Worley MD FHRS FACC The Heart Center Lancaster General Hospital Management of Venous Occlusion 2010

  2. Disclosures • I receive compensation in various forms from St Jude, Medtronic, Boston Scientific, Pressure Products, Biosense and Oscor Management of Venous Occlusion 2010

  3. What would you do if you saw this venogram? • Go to the other side • Extract one of the leads for access • Try to get a wire across and use progressively larger dilators • Try to get a wire across and do venoplasty Management of Venous Occlusion 2010

  4. Subclavian Venoplasty for Pacemaker and ICD Implantation • 10-30% with prior leads have subclavian vein stenosis/occlusion • We implant more frequently in patients with prior leads • CRT – requires unrestricted catheter and lead manipulation Management of Venous Occlusion 2010

  5. Venoplasty vs. Progressively Larger Dilators • Venoplasty is faster • Problems with dilators • catheters remain difficult to manipulate throughout the procedure. • distal stenosis (SVC/RA junction) is not opened Management of Venous Occlusion 2010

  6. Complications - Progressively Larger Dilators Management of Venous Occlusion 2010

  7. Our Experience with Subclavian Venoplasty • Began subclavian venoplasty in 1999. • 370 cases as of October 2010 • 8 EP physicians trained • No adverse clinical outcome • No distal embolization - chronic occlusion no thrombus • No venous disruption – veins heavily encased in scar tissue • No damage to the leads Management of Venous Occlusion 2010

  8. Basic System for Wire Resistant Subclavian Obstruction Management of Venous Occlusion 2010

  9. Local Venogram to Cross the Occlusion Management of Venous Occlusion 2010

  10. Range of Subclavian Obstruction • Moderate to severe – wire readily crosses the obstruction • Apparent total (wire resistant) – requires wire manipulation. • Total (wire refractory) – unable to get a wire across. Management of Venous Occlusion 2010

  11. Wires and Devices Used to “Cross” Obstruction or Occlusion • .035 Terumo Glidewire (angled with a torque device) • .018 glide wire (angled with a torque device) • .014 angioplasty wires designed to cross total occlusions • Terumo Crosswire • Cross-IT XT (100, 200, 300 in order of stiffness) Management of Venous Occlusion 2010

  12. using the 5 F dilator and glide wire to Cross the Occlusion Management of Venous Occlusion 2010

  13. System for Crossing Difficult Occlusions Management of Venous Occlusion 2010

  14. Vert to Direct Wire Peripheral Management of Venous Occlusion 2010

  15. Vert to Direct Wire Central Management of Venous Occlusion 2010

  16. Vert to Cross Total Management of Venous Occlusion 2010

  17. Total Occlusion – Unable to get a wire across Management of Venous Occlusion 2010

  18. Wire Under Insulation and Extraction for Venous Access Management of Venous Occlusion 2010

  19. Extraction & Wire Under Insulation Management of Venous Occlusion 2010

  20. Wire Under the Insulation Management of Venous Occlusion 2010

  21. Total Occlusion Unable to Cross with a Wire Management of Venous Occlusion 2010

  22. Laser Case - need venogram from the femoral vein to better define proximal lumen Management of Venous Occlusion 2010

  23. Laser Case Need to keep tip directed along leads must be confirmed in orthogonal views Management of Venous Occlusion 2010

  24. Total No Lead Laser Management of Venous Occlusion 2010

  25. Overall Success With Wire Refractory Subclavian Occlusion • Frontrunner alone 50% • Addition of Outback to Frontrunner 65% • Tornus 50% limited experience • Laser Wire 14 of 16 so far Management of Venous Occlusion 2010

  26. Balloons for Subclavian Venoplasty • .035 inch central lumen – usually get a glidewire across the obstruction. • Preferred size, 6 mm X 4 cm • Preferred type, non compliant (rated burst = 15 atm) (e.g. PowerFlex-P3) • Ultra non compliant Kevlar balloon if the waist is not relieved (rated burst = 30 atm) (e.g. Conquest) Management of Venous Occlusion 2010

  27. Always start “distally” - profile of the balloon increases after the first inflation called “Winging” Management of Venous Occlusion 2010

  28. Complications - Progressively Larger Dilators Management of Venous Occlusion 2010

  29. To prevent complications - always advance the glide wire into the PA before you inflate the balloon (or use progressively larger dilators) Video Management of Venous Occlusion 2010

  30. required Kevlar balloon Management of Venous Occlusion 2010

  31. Distal Obstruction Only Management of Venous Occlusion 2010

  32. Focused Force Venoplasty for a Focal Stenosis Refractory to Kevlar Management of Venous Occlusion 2010

  33. Focused Force VenoplastyRequired for Diffuse Narrowing Following Removal of an Over the Wire LV Lead Management of Venous Occlusion 2010

  34. Balloon Explodes Management of Venous Occlusion 2010

  35. Management of Venous Occlusion 2010

  36. Surgical LV Lead Placement at UVAAilawadi et al, Heart Rhythm 2010;7:619-625, 30 Day Mortality Transvenous = 2.5% Surgical = 4.8% Management of Venous Occlusion 2010

  37. Surgical LV Lead Placement UVA Charlottesville Post Procedure Complications • Acute renal injury = 26.2% surgical vs. 4.9% transvenous (P .001) • Infection = 11.9% surgical vs. 2.4% transvenous (P .03) • 30 day mortality via thoracotomy = 7.1% • 30 Day Mortality = 2.5% transvenous vs. 4.7% surgical Ailawadi G et al Heart Rhythm 2010;7:619–625 Management of Venous Occlusion 2010

  38. REPLACE Registry • Thus 435 patients had an LV lead related procedure (add or replace a lead) • 89% success thus 47 patients had failed LV lead placement • 4 deaths occurred at the time of surgical LV lead placement • 8.5% (4/47) surgical mortality if all 47 went for a surgical lead Management of Venous Occlusion 2010

  39. Total Occlusion No Leads to Extract or Follow Management of Venous Occlusion 2010

  40. Management of Venous Occlusion 2010

  41. Why Learn Venoplasty Techniques? • Occlusions are usually not clinically apparent • Not practical to obtain an interventional consult in the middle of the case • Reduces case time. • Reduces the need to Implant on the opposite side or perform laser lead extraction If you don’t do venoplasty it will likely not get done Management of Venous Occlusion 2010

  42. The End Management of Venous Occlusion 2010

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