Successful Right Ventricular Lead Placement Through a Collateral Following Subclavian Vein Occlusion

DOI: 10.19102/icrm.2010.010905

RAKESH GOPINATHANNAIR, MD, MA, SALAM SBAITY, MD, GARY GOLDSMITH, RTR and BRIAN OLSHANSKY, MD, FHRS, FACC, FAHA

Division of Cardiovascular Medicine, University of Iowa Hospitals, Iowa City, IA

The authors report no conflicts of interest for the published content.
Manuscript submitted August 18, 2010, final version accepted August 31, 2010.
Address correspondence to: Brian Olshansky, MD, Professor of Medicine, University of Iowa Hospitals, 200 Hawkins Drive, 4426a JCP, Iowa City, IA 52242. E-mail: Brian-Olshansky@uiowa.edu

An 88-year-old man with bradycardia requiring a pacemaker developed progressive elevation of right ventricular pacing thresholds requiring positioning of a new right ventricular lead. Left subclavian venography performed before obtaining access showed 1) near complete obstruction where the existing atrial and ventricular leads entered the vein, and 2) a more proximal, markedly tortuous, venous collateral of the left subclavian vein that crossed the midline and then into the superior vena cava. Guidewires could not traverse the subclavian vein but could be advanced into the superior vena cava through the collateral. Despite inner pacemaker lead stylets of various shapes and stiffness, and despite long and short sheaths that could traverse the sharp angle of the collateral, we could not deploy the lead past the bend due to kinking of the sheaths. Use of a woven 7 Fr Dacron coronary sinus sheath, stiff enough to maintain patency to navigate around the bend, then allowed lead deployment and subsequent successful placement into the right ventricle. A post-procedure chest X-ray that clearly demonstrates the tortuous course of the lead is shown.

Editor-in-Chief

This is the first report of a right ventricular lead placement through a collateral vein utilizing a stiff preformed sheath. This case also highlights the utility of venography as well as innovative use of non-conventional equipment to guide lead placement in a patient who has chronic pacemaker leads.