Placement of Transvenous Pacemaker and ICD Leads Across Total Chronic Occlusions

Objective: To establish a method of implantation for device leads across total venous occlusions. Background: Indications for pacemaker and implantable cardiac defibrillator implantation continue to expand. Chronic venous occlusions are increasingly encountered with lead placement. Some degree of obstruction can be as high as 13% before device implantation and 50% after transvenous device implantation. We report an approach of venoplasty/dilatation of chronic total occlusions to allow lead placement. Methods: From January 1, 2002 through December 16, 2004, 1,356 systems (initial and upgrade) were implanted at the University of Virginia. At the time of device implant, seven patients were noted to have chronic venous occlusions and alternative access was precluded. Four of the seven patients had an existing system; the other three received initial implantations. Subsequently, these seven patients had a 5 Fr catheter placed in the basilic/axillary/subclavian vein and a venogram was obtained to demonstrate the area of chronic occlusion. A guide wire was advanced across the lesion for initial recanalization. Dilatation or venoplasty was performed at the occluded site. A guide wire was retained across the lesion and the patient underwent lead implantation. Results: In all seven patients, recanalization was achieved and leads were successfully placed. There were no complications or damage to the vessels or existing leads. Conclusions: Venoplasty or dilatation of chronic total venous occlusion is a safe and effective technique, which allows for placement of transvenous leads.