A pacemaker-associated central occlusion complicating a transposed basilic fistula.
A 68-year-old male patient was seen for dialysis access. He was dialyzing via a right IJ permacath and had a left sided pacemaker present for approximately a year. A venogram of the right upper extremity showed a usable basilic vein and clear central vessels with a right IJ permacath and the pacemaker leads coming in from the left (images #1 and #2). A right transposed basilic fistula was performed in two stages and quickly cleared for use. The permacath was removed shortly after in the late Spring.
In November of that year, the patient presented with right arm swelling. To our surprise, the left-sided pacemaker had been removed for infection and placed with leads inserted via a right subclavian approach in the outflow of our fistula, precipitating a subclavian occlusion and symptomatic venous hypertension (image #3). The fistula was well developed and worth saving (images #4 and 5), so we elected to try to rescue it. A persistent radiologist (Dr. Paul Arpasi) created a stent bypass through collaterals in stages during a waxing and waning course of three temporarily successful interventions followed by recurrent arm swelling and re-intervention (images #6-11).
Pacemakers and shunts" image #1 – the pre-op peripheral venogram
The patient had an adequate basilic vein for a transposed basilic fistula.
“Pacemakers and shunts" image #2 – the pre-op central venogram
Although there is a right IJ permacath, and pacer leads coming from the left, the patient had clear central veins on the right.
"Pacemakers and shunts" image #3 – subclavian occlusion
In contrast to the pre-op venogram results, showing widely patent central veins, placement of a pacemaker with leads traversing the subclavian has destroyed the outflow of our fistula, creating a major avoidable problem for the patient.
"Pacemakers and shunts" images #4 and 5 – a functional fistula
Although the outflow has been destroyed and the patient’s arm is swollen, the fistula itself is good sized and with adequate flow – worth trying to save.
"Pacemakers and shunts" images #4 and 5 – a functional fistula
Although the outflow has been destroyed and the patient’s arm is swollen, the fistula itself is good sized and with adequate flow – worth trying to save.
"Pacemakers and shunts" images #6 and 7 – crossing the occlusion
Dr. Arpasi makes it look simple, but wending your way through a maze of little collaterals is no easy task. Each acute angle can be a struggle, and overlapping shadows may make a path look straight and continuous when it is not.
"Pacemakers and shunts" images #6 and 7 – crossing the occlusion
Dr. Arpasi makes it look simple, but wending your way through a maze of little collaterals is no easy task. Each acute angle can be a struggle, and overlapping shadows may make a path look straight and continuous when it is not.
"Pacemakers and shunts" images #8 and 9 – venoplasty and stent
Once the wire traverses the troubled segment, it can be dilated (above) and perhaps stented (below). We know that the result is not perfect, but when is “good” “good enough”? Time will tell. We want the swelling to go down for the patient’s comfort, and make the fistula easier to use.
"Pacemakers and shunts" images #8 and 9 – venoplasty and stent
Once the wire traverses the troubled segment, it can be dilated (above) and perhaps stented (below). We know that the result is not perfect, but when is “good” “good enough”? Time will tell. We want the swelling to go down for the patient’s comfort, and make the fistula easier to use.
"Pacemakers and shunts" images #10 and 11 – re-stenosis
After a short period of calm, arm swelling recurs, and the patient is brought back. Another stenosis is noted (above), and the stent is extended (below). Once again, a good result is obtained, for a while.
"Pacemakers and shunts" images #10 and 11 – re-stenosis
After a short period of calm, arm swelling recurs, and the patient is brought back. Another stenosis is noted (above), and the stent is extended (below). Once again, a good result is obtained, for a while.
"Pacemakers and shunts" images #12 and 13 – re-stenosis
After another short period of calm, arm swelling recurs a third time, and the patient is brought back. Another stenosis is noted (above), and the stent is re-extended (below), this time seeming to complete stenting of this segment. Note that the pacemaker has been removed.
"Pacemakers and shunts" images #12 and 13 – re-stenosis
After another short period of calm, arm swelling recurs a third time, and the patient is brought back. Another stenosis is noted (above), and the stent is re-extended (below), this time seeming to complete stenting of this segment. Note that the pacemaker has been removed.
"Pacemakers and shunts" images #14 and 15
So, predictably, the question comes up, “Why don’t you just take it out, and put something else in?” If it were only that easy.
A venogram of the other arm demonstrates that the first pacemaker, since removed from the left arm, also created significant damage. Venoplasty, stenting or a HeRO graft catheter would likely be required, turning the left side into another frustrating battle ground.
"Pacemakers and shunts" images #14 and 15
So, predictably, the question comes up, “Why don’t you just take it out, and put something else in?” If it were only that easy.
A venogram of the other arm demonstrates that the first pacemaker, since removed from the left arm, also created significant damage. Venoplasty, stenting or a HeRO graft catheter would likely be required, turning the left side into another frustrating battle ground.
Ironically, the patient again developed persistent bacteremia, attributed to the stents by the cardiologist, who suggested we remove them all, which we agreed to do if he could come up with proof that it was the stents that were infected. Finally, the second infected pacemaker was removed, with resolution of the bacteremia, and the final radiologic intervention by Dr. Arpasi completed an arch of stents from the right axillary vein to the right innominant vein (image#12-13).
The bottom line is that we spent a lot of time and effort compensating for the damage that a pacemaker placed in the outflow of a dialysis access caused. We did at least four interventions, placed five covered stents, treated a relapsing bacteremia with multiple courses of antibiotics and hospitalizations, and lost our central patency for a pacemaker that was in not quite a year, and didn’t benefit the patient at all.
Discussion
Knowing that the combination of a pacemaker and an ipsilateral dialysis shunt will cause symptomatic venous hypertension two-thirds of the time, we avoided the trap and went to the right side instead. Unfortunately, when the left-sided pacemaker had to be removed, the cardiologist saw no alternative but to place a right-sided pacemaker via the right subclavian route. We have warned patients against this, but they have returned later with arm swelling due to a pacemaker and access on the same side (The patient: “I told him what you said, but he said it wouldn’t matter”). It does. The usual course is multiple interventions which would not have been necessary otherwise, and a great deal of patient discomfort and inconvenience greatly increased costs, and frequently, loss of the access.
Strangely enough, it is very common for us to meet a patient who has had his pacemaker removed for infection, and when we ask about the plan for replacement to be told, “Oh, they said I didn’t need it anymore”. Did you ever, really?
Interventions on pacer-wire stenosis are fraught – I have seen a pacemaker wire cracked during a subclavian venoplasty, compressed against the clavicle by a high-pressure balloon, and I wonder about the potential lead erosion and failure caused by a stent rubbing against an insulated wire every time the patient moves his arm. People who say, “I’ve never seen it happen”, may not have been around long enough – but everyone’s an expert.
Similarly, alternatives exist, such as putting the pacer wires over the clavicle instead of under to avoid the bony canal between the clavicle and the first rib, but I have never seen a cardiologist do this. Epicardial pacemakers exist, but they require surgical implantation beyond the ability of most cardiologists. Finally, tiny wireless pacemakers implanted in the coronary sinus may soon be available widely, and transvenous pacemaker wires may become an anachronism. It can’t happen soon enough.
Epilogue
Predictably, the question comes up, “Why don’t you just take it out, and put something else in?” If it were only that easy.
A venogram of the other arm demonstrates that the first pacemaker, in for only a year more-or-less, and since removed from the left arm, also created significant damage. Venoplasty, stenting or a HeRO graft catheter would likely be required, turning the left side into another frustrating battleground. Better to avoid all this trouble from the beginning.
