Prevalence, management, and prediction of venous access site occlusion in patients undergoing lead revision surgery.

BACKGROUND: Implantable electronic cardiac devices (CIED) have emerged as an essential component in the treatment of cardiac arrhythmias and heart failure. Due to increased life expectancy, expanding indications and limited technical survival, an increasing number of revision procedures can be anticipated. Venous access site occlusion (VASO) is the main obstacle during revision surgery. In this retrospective study we evaluated the prevalence, predictive parameters and operative management of venous access site occlusion. METHODS AND RESULTS: Between 01/2016 and 12/2020 304 patients underwent lead revision surgery of transvenous CIED in our department. Prevalence of VASO was 25.7% (n = 78), one patient was symptomatic. Independent predicting clinical parameters were male sex (2.86 (1.39-5.87), p < 0.01) and lead age (1.11 (1.05-1.18), p < 0.01)). Revision surgery despite VASO was successful in 97.4% (n = 76) without prolongation of the total surgery time or higher complication rates. Yet, lead extraction was possible in 92% of patients with VASO vs. 98.2% of patients without VASO (p 0.01). CONCLUSION: VASO is a frequent condition in patients undergoing lead revision surgery, but successful revision is feasible in most cases without preceding lead extraction. However, the lower success rates of lead extractions may be prognostically relevant, especially for younger patients.

Usefulness of preoperative venography in patients with cardiac implantable electronic devices submitted to lead replacement or device upgrade procedures / Utilidade da Venografia Pré-Operatória em Procedimentos de Troca de Cabos-Eletrodos ou Mudança do Modo de Estimulação

Abstract Background: Venous obstructions are common in patients with transvenous cardiac implantable electronic devices, but they rarely cause immediate clinical problems. The main consequence of these lesions is the difficulty in obtaining venous access for additional leads implantation. Objectives: We aimed to assess the prevalence and predictor factors of venous lesions in patients referred to lead reoperations, and to define the role of preoperative venography in the planning of these procedures. Methods: From April 2013 to July 2016, contrast venography was performed in 100 patients referred to device upgrade, revision and lead extraction. Venous lesions were classified as non-significant (< 50%), moderate stenosis (51-70%), severe stenosis (71-99%) or occlusion (100%). Collateral circulation was classified as absent, discrete, moderate or accentuated. The surgical strategy was defined according to the result of the preoperative venography. Univariate analysis was used to investigate predictor factors related to the occurrence of these lesions, with 5% of significance level. Results: Moderate venous stenosis was observed in 23%, severe in 13% and occlusions in 11%. There were no significant differences in relation to the device side or the venous segment. The usefulness of the preoperative venography to define the operative tactic was proven, and in 99% of the cases, the established surgical strategy could be performed according to plan. Conclusions: The prevalence of venous obstruction is high in CIED recipients referred to reoperations. Venography is highly indicated as a preoperative examination for allowing the adequate surgical planning of procedures involving previous transvenous leads.

Resumo Fundamento: Obstruções venosas são frequentes em portadores de dispositivos cardíacos eletrônicos implantáveis (DCEI) endocárdicos, mas raramente causam problemas clínicos imediatos. A principal consequência destas lesões é a dificuldade para obtenção de via de acesso para o implante de novos cabos-eletrodos. Objetivos: Determinar a prevalência de lesões venosas em candidatos a reoperações envolvendo o manuseio de cabos-eletrodos, e definir o papel da venografia pré-operatória no planejamento desses procedimentos. Métodos: De abril de 2013 a julho de 2016, 100 pacientes com indicação de troca de cabos-eletrodos, ou mudança no modo de estimulação, realizaram venografia com subtração digital no período pré-operatório. As lesões venosas foram classificadas em: não significativas (< 50%), moderadas (51-70%), graves (71-99%) ou oclusivas (100%), e a circulação colateral, em ausente, discreta, moderada ou acentuada. A estratégia cirúrgica foi definida a partir do resultado deste exame. Empregou-se análise univariada para a pesquisa de fatores de risco relacionados à ocorrência dessas lesões, com nível de significância de 5%. Resultados: Obstruções venosas moderadas foram observadas em 23%, graves em 13% e oclusões em 11% dos pacientes estudados, não sendo identificadas diferenças significativas em sua distribuição em relação ao lado do implante, ou do segmento venoso. A utilidade do exame para definição da tática operatória foi comprovada, sendo que em 99% dos casos, a estratégia cirúrgica estabelecida pode ser executada. Conclusões: A prevalência de obstruções venosas é elevada em portadores de DCEI que serão submetidos a reoperações. A venografia é altamente indicada como exame pré-operatório para o adequado planejamento cirúrgico de procedimentos envolvendo cabos-eletrodos transvenosos previamente implantados.