management of venous occlusion: tunneling, venoplasty and ... · • thus 435 patients had an lv...
TRANSCRIPT
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Management of Venous Management of Venous Occlusion: Tunneling, Occlusion: Tunneling,
Venoplasty and Other TricksVenoplasty and Other Tricks
Seth J. Worley MD FHRS FACCSeth J. Worley MD FHRS FACCThe Heart CenterThe Heart Center
Lancaster General HospitalLancaster General Hospital
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Disclosures Disclosures
•• I receive compensation in various forms I receive compensation in various forms from St Jude, Medtronic, Boston Scientific, from St Jude, Medtronic, Boston Scientific, Pressure Products, Biosense and OscorPressure Products, Biosense and Oscor
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
What would you do if you saw this What would you do if you saw this venogram? venogram?
1.1. Go to the other sideGo to the other side2.2. Extract one of the Extract one of the
leads for accessleads for access3.3. Try to get a wire Try to get a wire
across and use across and use progressively larger progressively larger dilatorsdilators
4.4. Try to get a wire Try to get a wire across and do across and do venoplastyvenoplasty
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Subclavian Venoplasty for Subclavian Venoplasty for Pacemaker and ICD ImplantationPacemaker and ICD Implantation
•• 1010--30% with prior leads30% with prior leads have subclavian vein have subclavian vein stenosis/occlusionstenosis/occlusion
•• We implant more frequently in patients We implant more frequently in patients with prior leadswith prior leads
•• CRT CRT –– requires unrestricted catheter and requires unrestricted catheter and lead manipulationlead manipulation
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Venoplasty vs. Progressively Venoplasty vs. Progressively Larger DilatorsLarger Dilators
•• Venoplasty is faster Venoplasty is faster •• Problems with dilatorsProblems with dilators
–– catheters remain difficult to manipulate catheters remain difficult to manipulate throughout the procedure. throughout the procedure.
–– distal stenosis (SVC/RA junction) is not distal stenosis (SVC/RA junction) is not openedopened
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Complications Complications -- Progressively Progressively Larger DilatorsLarger Dilators
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Our Experience with Subclavian Our Experience with Subclavian VenoplastyVenoplasty
•• Began subclavian venoplasty in 1999. Began subclavian venoplasty in 1999. •• 370 cases as of October 2010370 cases as of October 2010•• 8 EP physicians trained 8 EP physicians trained •• No adverse clinical outcomeNo adverse clinical outcome
–– No distal embolization No distal embolization -- chronic occlusion no chronic occlusion no thrombus thrombus
–– No venous disruption No venous disruption –– veins heavily encased veins heavily encased in scar tissuein scar tissue
–– No damage to the leadsNo damage to the leads
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Basic System for Wire Resistant Basic System for Wire Resistant Subclavian Obstruction Subclavian Obstruction
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Local Venogram to Cross the Local Venogram to Cross the OcclusionOcclusion
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Range of Subclavian ObstructionRange of Subclavian Obstruction
•• Moderate to severe Moderate to severe –– wire readily crosses wire readily crosses the obstruction the obstruction
•• Apparent total (wire resistant) Apparent total (wire resistant) –– requires requires wire manipulation. wire manipulation.
•• Total (wire refractory) Total (wire refractory) –– unable to get a unable to get a wire across.wire across.
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Wires and Devices Used to Wires and Devices Used to ““CrossCross””Obstruction or OcclusionObstruction or Occlusion
•• .035 Terumo Glidewire (angled with a .035 Terumo Glidewire (angled with a torque device)torque device)
•• .018 glide wire (angled with a torque .018 glide wire (angled with a torque device)device)
•• .014 angioplasty wires designed to cross .014 angioplasty wires designed to cross total occlusions total occlusions –– Terumo CrosswireTerumo Crosswire–– CrossCross--IT XT (100, 200, 300 in order of IT XT (100, 200, 300 in order of
stiffness)stiffness)
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
using the 5 F dilator and glide wire using the 5 F dilator and glide wire to Cross the Occlusionto Cross the Occlusion
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
System for Crossing Difficult System for Crossing Difficult OcclusionsOcclusions
Vert to Direct Wire PeripheralVert to Direct Wire Peripheral
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Vert to Direct Wire CentralVert to Direct Wire Central
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Vert to Cross TotalVert to Cross Total
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Total Occlusion Total Occlusion –– Unable to Unable to get a wire acrossget a wire across
Wire Under Insulation and Extraction Wire Under Insulation and Extraction for Venous Access for Venous Access
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Extraction & Wire Under Extraction & Wire Under InsulationInsulation
Wire Under the InsulationWire Under the Insulation
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Total Occlusion Unable to Cross Total Occlusion Unable to Cross with a Wirewith a Wire
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Laser Case Laser Case -- need venogram need venogram from the femoral vein to better from the femoral vein to better
define proximal lumendefine proximal lumen
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Laser Case Laser Case Need to keep tip directed along Need to keep tip directed along
leads must be confirmed in leads must be confirmed in orthogonal viewsorthogonal views
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Total No Lead LaserTotal No Lead Laser
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Overall Success With Wire Overall Success With Wire Refractory Subclavian OcclusionRefractory Subclavian Occlusion
•• Frontrunner alone 50%Frontrunner alone 50%•• Addition of Outback to Frontrunner 65%Addition of Outback to Frontrunner 65%•• Tornus 50% limited experienceTornus 50% limited experience•• Laser Wire 14 of 16 so farLaser Wire 14 of 16 so far
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Balloons for Subclavian VenoplastyBalloons for Subclavian Venoplasty
•• .035 inch central lumen .035 inch central lumen –– usually get a usually get a glidewire across the obstruction.glidewire across the obstruction.
•• Preferred size, 6 mm X 4 cmPreferred size, 6 mm X 4 cm•• Preferred type, non compliant (rated burst Preferred type, non compliant (rated burst
= 15 atm) = 15 atm) ((e.g. PowerFlexe.g. PowerFlex--P3P3))•• Ultra non compliant Kevlar balloon if the Ultra non compliant Kevlar balloon if the
waist is not relieved (rated burst = 30 atm) waist is not relieved (rated burst = 30 atm) (e.g. Conquest)(e.g. Conquest)
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Always start Always start ““distallydistally”” -- profile of the balloon profile of the balloon increases after the first inflation called increases after the first inflation called
““WingingWinging””
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Complications Complications -- Progressively Progressively Larger DilatorsLarger Dilators
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
To prevent complications To prevent complications --alwaysalways advance the glide wire advance the glide wire
into the PA before you inflate the into the PA before you inflate the balloon (or use progressively balloon (or use progressively
larger dilators) Videolarger dilators) Video
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
required Kevlar balloonrequired Kevlar balloon
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Distal Obstruction OnlyDistal Obstruction Only
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Focused Force Venoplasty for a Focused Force Venoplasty for a Focal Stenosis Refractory to KevlarFocal Stenosis Refractory to Kevlar
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Focused Force VenoplastyFocused Force VenoplastyRequired for Diffuse Narrowing Following Required for Diffuse Narrowing Following
Removal of an Over the Wire LV LeadRemoval of an Over the Wire LV Lead
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Balloon ExplodesBalloon Explodes
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Surgical LV Lead Placement at UVASurgical LV Lead Placement at UVAAilawadi et al, Heart Rhythm 2010;7:619Ailawadi et al, Heart Rhythm 2010;7:619--625625,,
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
30 Day MortalityTransvenous = 2.5%Surgical = 4.8%
Surgical LV Lead Placement UVA Charlottesville Surgical LV Lead Placement UVA Charlottesville Post Procedure ComplicationsPost Procedure Complications
•• Acute renal injury = 26.2% surgical vs. Acute renal injury = 26.2% surgical vs. 4.9% transvenous (4.9% transvenous (P .001) P .001)
•• Infection = 11.9% surgical vs. 2.4% Infection = 11.9% surgical vs. 2.4% transvenous (P .03)transvenous (P .03)
•• 30 day mortality via thoracotomy = 7.1%30 day mortality via thoracotomy = 7.1%•• 30 Day Mortality = 2.5% transvenous vs. 30 Day Mortality = 2.5% transvenous vs.
4.7% surgical4.7% surgical
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Ailawadi G et al Heart Rhythm 2010;7:619–625
REPLACE RegistryREPLACE Registry
•• Thus 435 patients had an LV lead related Thus 435 patients had an LV lead related procedure (add or replace a lead)procedure (add or replace a lead)–– 89% success thus 47 patients had failed LV 89% success thus 47 patients had failed LV
lead placementlead placement–– 4 deaths occurred at the time of surgical LV 4 deaths occurred at the time of surgical LV
lead placementlead placement•• 8.5% (4/47) surgical mortality if all 47 went 8.5% (4/47) surgical mortality if all 47 went
for a surgical leadfor a surgical lead
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Total Occlusion No Leads to Total Occlusion No Leads to Extract or FollowExtract or Follow
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
Why Learn Venoplasty Why Learn Venoplasty Techniques?Techniques?
•• Occlusions are usually not clinically apparentOcclusions are usually not clinically apparent•• Not practical to obtain an interventional consult Not practical to obtain an interventional consult
in the middle of the casein the middle of the case•• Reduces case time.Reduces case time.•• Reduces the need to Implant on the opposite Reduces the need to Implant on the opposite
side or perform laser lead extractionside or perform laser lead extractionIf you donIf you don’’t do venoplasty it will likely not get donet do venoplasty it will likely not get done
October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD
The EndThe End