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Outcomes of Symptomatic Device Lead-Related Venous Obstruction
Quick Takes
- Patients with transvenous implantable cardiac electronic devices have a high risk of symptomatic lead-related venous obstruction (5% incidence rate).
- Lead extraction is associated with less utilization of health care resources for symptomatic venous obstruction compared to conservative management and to percutaneous venoplasty.
Study Questions:
What is the incidence and clinical impact of lead-related venous obstruction (LRVO) among patients with cardiovascular implantable electronic devices (CIEDs)?
Methods:
The authors examined Medicare records for LRVO status.
Results:
There were nearly 650,000 patients with CIED implants, among whom 5% developed LRVO at a follow-up to 5 years. Independent predictors of LRVO included CIEDs with >1 lead (hazard ratio [HR], 1.09), chronic kidney disease (HR, 1.17), and malignancies (HR, 1.23). Most LRVO patients (85%) were managed conservatively. Among the remaining 15% of patients undergoing intervention, 74% underwent CIED extraction and 26% percutaneous revascularization; 90% of the patients did not receive another CIED after extraction, and there was low use (2%) of leadless pacemakers. Extraction was associated with significant reductions in LRVO-related health care utilization (adjusted rate ratio, 0.58) compared to conservative management.
Conclusions:
The authors conclude that the incidence of LRVO is 1 of every 20 patients with CIEDs and that extraction was associated with long-term reduction in recurrent health care utilization.
Perspective:
Patients with LRVO may be asymptomatic, where the diagnosis is made incidentally or at the time of a venous intervention. Patients may also present with upper extremity deep venous thrombosis, limb or facial swelling, and superior vena cava syndrome. Prior studies have shown that the prevalence of LRVO may be as high as 30% in some cohorts following CIED implantation. The authors of the present study report a 5% symptomatic LRVO rate. Only 15% of LRVO patients were managed with CIED extraction, which carries a Class I recommendation for symptomatic CIED-associated venous obstruction in the current guidelines.
In the present study, patients presented with symptomatic LRVO at a median time of 0.6 years after the CIED implant, a time favorable for lead explanation. The authors identified three risk factors for LRVO: 1) having more than a one transvenous lead, 2) the presence of chronic kidney disease, and 3) the comorbidity of a malignancy. Finally, the authors found that CIED extraction is associated with a 40% reduction in LRVO-related health care utilization, compared to conservative treatment, further highlighting the apparent underutilization of lead extraction. Interestingly, percutaneous revascularization was not associated with a reduction in LRVO-related health care utilization.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure
Keywords: Arrhythmias, Cardiac, Conservative Treatment, Defibrillators, Implantable, Device Removal, Health Resources, Heart Failure, Kidney Diseases, Myocardial Ischemia, Myocardial Revascularization, Neoplasms, Pacemaker, Artificial, Renal Insufficiency, Chronic, Thrombosis, Treatment Outcome, Vascular Diseases
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