Venous Obstruction in Asymptomatic Patients Undergoing First Implantation or Revision of a Cardiac Pacemaker or Implantable Cardioverter-Defibrillator: A Retrospective Single Center Analysis

Abstract

Purpose: To investigate the incidence and possible risk factors of upper deep vein obstruction in patients both prior to first cardiac device implantation and before device revision.

Materials and Methods: Records of asymptomatic patients undergoing contrast venography prior to implantation or revision of a cardiac device from 09/2009 to 04/2012 were reviewed. Venograms were used to determine the presence of venous obstruction. Interrelations between the incidence of venous obstruction and patient- or device-related parameters were identified using Fisher's exact test and univariate logistic regression. Multivariate logistic regression was used to identify independent predictors of venous obstruction.

Results: 456 patients met the inclusion criteria (330 males, 126 females, 67.8 ± 12.9 years). 100 patients underwent first implantation, and 356 patients underwent device revision (mean time since implantation 82.5 ± 75.3 months). Venous obstruction was present in 11.0 % and 30.1 % before implantation and revision, respectively. Only presence of ventricular escape rhythm was significantly related to venous occlusion (p < 0.001) prior to first implantation. Prior to revision, significant predictors were male sex (p = 0.01), time since implantation (p < 0.0001), presence of escape rhythm (p = 0.02), compromised coagulation (p = 0.02), phenprocoumon (p = 0.005), and peripheral arterial disease (p = 0.01).

Conclusion: Although several risk factors could be identified, reliable prediction of venous obstruction was not possible. Therefore, we advocate performing venography in all patients prior to device revision or upgrade to avoid complications. In cases of first device implantation, the risks associated with venography should be weighed against the surprisingly high rate of deep upper vein obstruction.

Key points:

• Prevalence of upper extremity deep vein obstruction is surprisingly high.

• Reliable prediction of venous obstruction is not possible.

• Contrast venography should be performed prior to device revision/upgrade.

• Before first implantation procedure-related risks must be weighed against high obstruction rates.

Citation Format:

• Pieper CC, Weis V, Fimmers R et al. Venous Obstruction in Asymptomatic Patients Undergoing First Implantation or Revision of a Cardiac Pacemaker or Implantable Cardioverter-Defibrillator: A Retrospective Single Center Analysis. Fortschr Röntgenstr 2015; 187: 1029 – 1035

Zusammenfassung

Ziel: Untersuchung der Inzidenz und möglicher Risikofaktoren von Obstruktionen der tiefen oberen Extremitätenvenen bei Patienten vor Erstimplantation und Revision von aktiven Herzimplantaten.

Material und Methoden: Daten von asymptomatischen Patienten, die sich zwischen 09/2009 und 04/2012 einer Erstimplantation oder Revision eines aktiven Herzimplantates unterzogen haben, wurden ausgewertet. Das Vorliegen venöser Obstruktionen wurde mittels Venografie untersucht. Zusammenhänge zwischen Inzidenz einer venösen Obstruktion und patientenbezogenen sowie geräteabhängigen Faktoren wurden mittels exaktem Fischer-Test und univariater logistischer Regression untersucht. Eine multivariate logistische Regression wurde verwendet, um unabhängige Prädiktoren einer venösen Obstruktion zu bestimmen.

Ergebnisse: 456 Patienten erfüllten die Einschlusskriterien (330 Männer, 126 Frauen, 67,8 ± 12,9 Jahre). Bei 100 Patienten wurde eine Erstimplantation, bei 356 eine Revision durchgeführt (mittlere Zeit seit der Implantation 82,5 ± 75,3 Monate). Venöse Obstruktionen wurden bei 11,0 % vor Erstimplantation bzw. 30,1 % vor Revision beobachtet. Ein Ventrikelersatzrhythmus war als einziger Faktor signifikant mit dem Auftreten einer Okklusion vor Erstimplantation assoziiert (p < 0,001). Vor Revisionen konnten männliches Geschlecht (p = 0.01), Zeit seit Implantation (p < 0,0001), Ersatzrhythmus (p = 0,02), beeinträchtigte Gerinnungssituation (p = 0,02), Phenprocoumontherapie (p = 0,005) und peripher arterielle Verschlusskrankheit (p = 0,01) als unabhängige Prädiktoren identifiziert werden.

Schlussfolgerung: Obwohl mehrere Risikofaktoren identifiziert werden konnten, ist eine verlässliche Vorhersage einer venösen Obstruktion nicht möglich. Wir empfehlen die Durchführung einer Venografie zur Vermeidung von Komplikationen bei allen Patienten vor Revision oder Aufrüstung eines Implantates. Vor Erstimplantationen müssen die Risiken einer Venografie gegen die überraschend hohe Rate an tiefen Armvenenobstruktionen abgewogen werden.

Key Points:

• Die Prävalenz einer Obstruktion der tiefen oberen Extremitätenvenen ist erstaunlich hoch.

• Eine verlässliche Vorhersage einer venösen Obstruktion ist nicht möglich.

• Eine Kontrastvenografie sollte vor jeder Implantatrevision und jeder Aufrüstung durchgeführt werden.

• Vor Erstimplantation sollten prozedurale Risiken gegen die hohen Obstruktionsraten abgewogen werden.

Key words

veins - angiography - obstruction/occlusion - implantable cardioverter-defibrillator - pacemaker - venography

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