1. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Management of Venous Occlusion: Tunneling, Venoplasty and Other Tricks Seth J. Worley MD FHRS FACC Seth J. Worley MD FHRS FACC The Heart Center Lancaster General Hospital

2. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Disclosures I receive compensation in various forms from St Jude, Medtronic, Boston Scientific, Pressure Products, Biosense and OscorI receive compensation in various forms from St Jude, Medtronic, Boston Scientific, Pressure Products, Biosense and Oscor

3. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD What would you do if you saw this venogram? 1.Go to the other side 2.Extract one of the leads for access 3.Try to get a wire across and use progressively larger dilators 4.Try to get a wire across and do venoplasty

4. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Subclavian Venoplasty for Pacemaker and ICD Implantation 10-30% with prior leads have subclavian vein stenosis/occlusion10-30% with prior leads have subclavian vein stenosis/occlusion We implant more frequently in patients with prior leadsWe implant more frequently in patients with prior leads CRT – requires unrestricted catheter and lead manipulationCRT – requires unrestricted catheter and lead manipulation

5. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Venoplasty vs. Progressively Larger Dilators Venoplasty is fasterVenoplasty is faster Problems with dilatorsProblems with dilators –catheters remain difficult to manipulate throughout the procedure. –distal stenosis (SVC/RA junction) is not opened

6. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Complications - Progressively Larger Dilators

7. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Our Experience with Subclavian Venoplasty Began subclavian venoplasty in 1999.Began subclavian venoplasty in 1999. 370 cases as of October 2010370 cases as of October 2010 8 EP physicians trained8 EP physicians trained No adverse clinical outcomeNo adverse clinical outcome –No distal embolization - chronic occlusion no thrombus –No venous disruption – veins heavily encased in scar tissue –No damage to the leads

8. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Basic System for Wire Resistant Subclavian Obstruction

9. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Local Venogram to Cross the Occlusion

10. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Range of Subclavian Obstruction Moderate to severe – wire readily crosses the obstructionModerate to severe – wire readily crosses the obstruction Apparent total (wire resistant) – requires wire manipulation.Apparent total (wire resistant) – requires wire manipulation. Total (wire refractory) – unable to get a wire across.Total (wire refractory) – unable to get a wire across.

11. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Wires and Devices Used to “Cross” Obstruction or Occlusion.035 Terumo Glidewire (angled with a torque device).035 Terumo Glidewire (angled with a torque device).018 glide wire (angled with a torque device).018 glide wire (angled with a torque device).014 angioplasty wires designed to cross total occlusions.014 angioplasty wires designed to cross total occlusions –Terumo Crosswire –Cross-IT XT (100, 200, 300 in order of stiffness)

12. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD using the 5 F dilator and glide wire to Cross the Occlusion

13. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD System for Crossing Difficult Occlusions

14. Vert to Direct Wire Peripheral October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

15. Vert to Direct Wire Central October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

16. Vert to Cross Total October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

17. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Total Occlusion – Unable to get a wire across

18. Wire Under Insulation and Extraction for Venous Access October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

19. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Extraction & Wire Under Insulation

20. Wire Under the Insulation October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

21. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Total Occlusion Unable to Cross with a Wire

22. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Laser Case - need venogram from the femoral vein to better define proximal lumen

23. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Laser Case Need to keep tip directed along leads must be confirmed in orthogonal views

24. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Total No Lead Laser

25. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Overall Success With Wire Refractory 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

26. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Balloons for Subclavian Venoplasty.035 inch central lumen – usually get a glidewire across the obstruction..035 inch central lumen – usually get a glidewire across the obstruction. Preferred size, 6 mm X 4 cmPreferred size, 6 mm X 4 cm Preferred type, non compliant (rated burst = 15 atm) ( e.g. PowerFlex-P3 )Preferred type, non compliant (rated burst = 15 atm) ( e.g. PowerFlex-P3 ) Ultra non compliant Kevlar balloon if the waist is not relieved (rated burst = 30 atm) (e.g. Conquest)Ultra non compliant Kevlar balloon if the waist is not relieved (rated burst = 30 atm) (e.g. Conquest)

27. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Always start “distally” - profile of the balloon increases after the first inflation called “Winging”

28. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Complications - Progressively Larger Dilators

29. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD To prevent complications - always advance the glide wire into the PA before you inflate the balloon (or use progressively larger dilators) Video

30. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD required Kevlar balloon

31. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Distal Obstruction Only

32. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Focused Force Venoplasty for a Focal Stenosis Refractory to Kevlar

33. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Focused Force Venoplasty Required for Diffuse Narrowing Following Removal of an Over the Wire LV Lead

34. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Balloon Explodes

35. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

36. Surgical LV Lead Placement at UVA Ailawadi et al, Heart Rhythm 2010;7:619-625, October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD 30 Day Mortality Transvenous = 2.5% Surgical = 4.8%

37. Surgical LV Lead Placement UVA Charlottesville Post Procedure Complications Acute renal injury = 26.2% surgical vs. 4.9% transvenous (P.001)Acute renal injury = 26.2% surgical vs. 4.9% transvenous (P.001) Infection = 11.9% surgical vs. 2.4% transvenous (P.03)Infection = 11.9% surgical vs. 2.4% transvenous (P.03) 30 day mortality via thoracotomy = 7.1%30 day mortality via thoracotomy = 7.1% 30 Day Mortality = 2.5% transvenous vs. 4.7% surgical30 Day Mortality = 2.5% transvenous vs. 4.7% surgical October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Ailawadi G et al Heart Rhythm 2010;7:619–625

38. REPLACE Registry Thus 435 patients had an LV lead related procedure (add or replace a lead)Thus 435 patients had an LV lead related procedure (add or replace a lead) –89% success thus 47 patients had failed LV lead placement –4 deaths occurred at the time of surgical LV lead placement 8.5% (4/47) surgical mortality if all 47 went for a surgical lead8.5% (4/47) surgical mortality if all 47 went for a surgical lead October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

39. Total Occlusion No Leads to Extract or Follow October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

40. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD

41. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD Why Learn Venoplasty Techniques? Occlusions are usually not clinically apparentOcclusions are usually not clinically apparent Not practical to obtain an interventional consult in the middle of the caseNot practical to obtain an interventional consult in the middle of the case Reduces case time.Reduces case time. Reduces the need to Implant on the opposite side or perform laser lead extractionReduces the need to Implant on the opposite side or perform laser lead extraction If you don’t do venoplasty it will likely not get done If you don’t do venoplasty it will likely not get done

42. October 8, 2010 Management of Venous Occlusion 2010 Seth J Worley MD The End