Are Endovascular Interventions for Central Vein Obstructions due to Cardiac Implanted Electronic Devices Effective?

Venous complications of pacemaker/ implantable cardioverter defibrillator (ICD) system implantation rarely cause immediate clinical problems. The challenge starts when patients come for system revision or upgrade. Numerous reports of venous complications such as stenosis, occlusions, and superior vena cava syndrome have been published. We reviewed current knowledge of these complications, management, and their impact on upgrade/revision procedures. One study has suggested that intravenous lead infection promotes local vein stenosis. Another found that the presence of a temporary wire before implantation is associated with an increased risk of stenosis. Although data for ICD leads is based only on three studies-it suggests that the rate of venous complications is very similar to that of pacing systems, and probably data from pacing leads can be extrapolated to ICD leads. Despite 40 years of experience with transcutaneous implanted intravenous pacing systems and dozens of studies, we were unable to identify clear risk factors (confirmed by independent studies) that lead to venous stenosis. Neither the hardware (lead size, number and material) nor the access site choice (cephalic cut down, subclavian or axillary puncture) appears to affect rate of venous complications. A few factors were proposed as predictors of severe venous stenosis/occlusion: presence of multiple pacemaker leads (compared to a single lead), use of hormone therapy, personal history of venous thrombosis, the presence of temporary wire before implantation, previous presence of a pacemaker (ICD as an upgrade) and the use of dual-coil leads. Anticoagulant therapy (for other reasons than pacemaker lead) seemed to have protective antithrombotic effect.

Pacemaker lead implantation can cause thrombosis, which can be associated with serious local morbidity and complicated by pulmonary embolism. Few reliable estimates of the incidence of thrombosis have been reported. The contribution of established risk factors to venous thrombosis in patients with implanted pacemaker leads is unknown. One hundred forty-five consecutive patients n = 145) underwent routine clinical and Doppler ultrasound evaluation for thrombosis before and 3, 6, and 12 months after lead implantation. Established risk factors for venous thrombosis were assessed in detail for all patients. Clinical outcome, including clinically manifest thrombosis, pulmonary embolism, associated pacemaker lead infection, complicated reinterventions, and death, was evaluated. Thrombosis was observed in 34 (23%) of 145 patients. Thrombosis did not cause any signs or symptoms in 31 patients but resulted in overt clinical symptoms in 3 patients. The absence of anticoagulant therapy, use of hormone therapy, and a personal history of venous thrombosis were associated with an increased risk of thrombosis. The risk of thrombosis increased in the presence of multiple pacemaker leads compared to a single lead. Established risk factors for venous thrombosis and the presence of multiple pacemaker leads contribute substantially to the occurrence of thrombosis associated with permanent pacemaker leads. Risk factor assessment prior to implantation may be useful for identifying patients at risk for thrombotic complications. Preventive management in these patients is warranted.

A worldwide cardiac pacing and implantable cardioverter-defibrillator (ICD) survey was undertaken for calendar year 2005 and compared to a similar survey conducted in 2001. There were contributions from 43 countries: 16 from Europe, 13 from the Asia Pacific region, four from the Middle East and Africa, and 10 from the Americas. The United States had the largest number of cardiac pacemaker implants (223,425). Virtually all countries showed increases in implant numbers over the 4 years. High-degree atrioventricular block and sick sinus syndrome remain the major indications for implantation of a cardiac pacemaker, although indications data were not available for large implanting regions such as Europe, Australia, and the United States. There remains a high percentage of VVI(R) pacing in the developing countries, although compared to the 2001 survey, virtually all countries had increased the percentage of DDDR implants, together with a fall in single-lead VDD implants. Pacing leads were predominantly transvenous, bipolar, and passive fixation. There was, however, an increased use of active fixation leads in both the atrium and ventricle. All countries surveyed showed a significant rise in the use of ICDs with the largest implanter being the United States (119,121) with 401 new implants per million population. Although the numbers of participating countries have fallen, there still remains a group of loyal enthusiastic survey coordinators. Recruitment of new coordinators will hopefully continue in order to obtain a fully global experience of cardiac pacing and ICD usage.