Utility and safety of axillo-subclavian venous imaging with carbon dioxide (CO) prior to chronic lead system revisions.
BACKGROUND
Prior to attempting placement of one or more electrodes to revise existing rhythm control devices, patency of the central veins should be documented, in view of a high incidence of significant chronic occlusions. Since iodinated contrast venography may be contraindicated in select situations, imaging of the axillo-subclavian venous system with gaseous carbon dioxide (CO(2)) was evaluated prospectively in 23 consecutive individuals who were considered for revision of previously implanted pacemaker or automatic cardioverter defibrillator lead systems.


METHODS
Approximately 20 mL of CO(2) were manually infused via CO(2) primed injection tubing into a vein at or above the level of the antecubital fossa ipsilateral to the side of prior lead placements. Digital subtraction imaging over the axillo-subclavian region, lower neck, and mediastinum was performed. Formal interpretation was obtained from one of three interventional radiologists and at least one electrophysiologist.


RESULTS
Significant venous occlusions were identified in five (22%) patients. Vascular access utilized for the subsequent 18 revisions performed included the imaged patent ipsilateral vein in 14 patients and the contralateral, right-sided subclavian venous system in three patients. One patient required epicardial left ventricular lead placement. There were no complications from venography.


CONCLUSIONS
Axillo-subclavian venography with gaseous CO(2) in patients undergoing pacemaker or implantable cardioverter defibrillator lead revisions is feasible and safe when use of iodinated dye is contraindicated. This technique should be employed in patients with azotemia, dye contrast allergies, or significant inflammation in the vicinity of the intravenous line insertion.
Winters
Stephen L
SL
Gagnon Cardiovascular Institute, Morristown, New Jersey 07962-1956, USA. Stephen.winters@atlantichealth.org
Curwin
Jay H
JH
Sussman
Jonathan S
JS
Coyne
Robert F
RF
Calhoun
Sean K
SK
Yablonsky
Thaddeus M
TM
Schwartz
Jeanne R
JR
Quinlan
Karen
K
D000368:Aged; D002245:Carbon Dioxide; D003287:Contrast Media; D020878:Device Removal / Q000379:methods*; D004567:Electrodes, Implanted; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D008297:Male; D010690:Phlebography / Q000379:methods*; D013350:Subclavian Vein / Q000000981:diagnostic imaging*
D003287:Contrast Media; D002245:Carbon Dioxide