Excimer laser to open refractory subclavian occlusion in 12 consecutive patients

Background Ideally, new leads are placed via the axillary/cephalic vein on the same side as the initial implant; however, 3.6% to 9% of patients have chronic total subclavian/innominate occlusion. In most cases, a wire can be manipulated across the occlusion and venoplasty safely performed. Occasionally, a wire will not cross, and additional tools are required. Objective The purpose of this study was to evaluate our experience with an excimer laser catheter used to cross wire-refractory chronic total subclavian/innominate occlusion in 12 patients. Methods We first used the laser to successfully cross a lead-related chronic total occlusion that did not yield to either a wire or microdissection. We subsequently used the laser for 11 additional wire-refractory occlusions. We reviewed the implant reports, hospital records, and videos of each case. Results The occlusions were successfully crossed and a wire placed for venoplasty in 11 of 12 cases by one of three implanting physicians. No complications occurred, and the existing leads sustained no damage. Conclusion Although the safety of the procedure remains uncertain, if directions are followed and are precautions heeded, physicians with training and experience in venoplasty and laser lead extraction can learn this technique, which provides an important option for adding a lead to an existing device when the ipsilateral access vein is occluded.