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An Extreme Example of Subclavian Crush
JACC: CLINICAL ELECTROPHYSIOLOGY
VOL.
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2016
ISSN 2405-500X/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacep.2016.05.012
IMAGES IN ELECTROPHYSIOLOGY
An Extreme Example of Subclavian Crush George H. Crossley, MD, Sam Aznaurov, MD, Matthew R. Danter, MD, Christopher Ellis, MD
T
he patient presented in 2008 for follow-up of her
implantable
cardioverter-defibrillator,
F I G U R E 1 Chest Radiograph and High Resolution Inset
which had reached its elective replacement
indicator. The ventricular lead was a Medtronic 6949 lead (Minneapolis, Minnesota), which was electively replaced with the current Medtronic 6947. There was distortion of the superior vena cava coil prior to extraction, at the same position seen in Figure 1. The new lead displayed some distortion of the coil on the post-operative film. Gradually the abnormality seen here developed, with increased distortion and fractures of the proximal coil. Eventually, noise was seen on the pace/sense component and high impedance was noted on the SVC coil. It is clear that the proximal coil extends out of the vein and through the subclavius muscle. Soft tissue mobility has led the pulse generator to migrate, putting force on the lead at the point of intravascular adhesions. The free metal pieces are elements of the SVC coil that have fractured. The extraction was exceedingly difficult. The lead
locking stylet did not pass beyond the SVC coil.
Chest radiography and detail inset—superior vena cava coil disruption at vascular access site.
Eventually, a 16-F laser sheath was advanced over the shredded coils, freeing up the binding site at the
elements. This provides yet another reason not to use
proximal end of the SVC coil. The lead was then easily
dual coil leads and likewise not to use a very central
withdrawn. The lead was replaced with a single coil
venous access site.
lead, which was placed via a separate, more lateral axillary vein access, avoiding contact with the sev-
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
ered elements of the coils.
George H. Crossley, Heart and Vascular Institute,
The likely mechanism of this fracture is the action
Vanderbilt University, 1215 21st Avenue North, Nash-
of connective tissue on the coils. The fractured ele-
ville,
ments then serve to disrupt other elements of the
[email protected].
Tennessee
37232-8802.
E-mail:
lead. Once the integrity of the coil is lost, a fulcrum mechanism may cause fracture of the pace/sense
KEY WORDS defibrillator, lead failure, subclavian crush
From the Vanderbilt University Heart and Vascular Institute, Nashville, Tennessee. Dr. Crossley has received speaking and consulting fees from Medtronic and Boston Scientific. Dr. Ellis has received consulting fees from Spectranetics; has received research support and consulting fees from Medtronic and Boston Scientific; and has served on the advisory boards of Medtronic and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 25, 2016; revised manuscript received May 18, 2016, accepted May 26, 2016.
George.
VOL.
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2016
ISSN 2405-500X/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacep.2016.05.012
IMAGES IN ELECTROPHYSIOLOGY
An Extreme Example of Subclavian Crush George H. Crossley, MD, Sam Aznaurov, MD, Matthew R. Danter, MD, Christopher Ellis, MD
T
he patient presented in 2008 for follow-up of her
implantable
cardioverter-defibrillator,
F I G U R E 1 Chest Radiograph and High Resolution Inset
which had reached its elective replacement
indicator. The ventricular lead was a Medtronic 6949 lead (Minneapolis, Minnesota), which was electively replaced with the current Medtronic 6947. There was distortion of the superior vena cava coil prior to extraction, at the same position seen in Figure 1. The new lead displayed some distortion of the coil on the post-operative film. Gradually the abnormality seen here developed, with increased distortion and fractures of the proximal coil. Eventually, noise was seen on the pace/sense component and high impedance was noted on the SVC coil. It is clear that the proximal coil extends out of the vein and through the subclavius muscle. Soft tissue mobility has led the pulse generator to migrate, putting force on the lead at the point of intravascular adhesions. The free metal pieces are elements of the SVC coil that have fractured. The extraction was exceedingly difficult. The lead
locking stylet did not pass beyond the SVC coil.
Chest radiography and detail inset—superior vena cava coil disruption at vascular access site.
Eventually, a 16-F laser sheath was advanced over the shredded coils, freeing up the binding site at the
elements. This provides yet another reason not to use
proximal end of the SVC coil. The lead was then easily
dual coil leads and likewise not to use a very central
withdrawn. The lead was replaced with a single coil
venous access site.
lead, which was placed via a separate, more lateral axillary vein access, avoiding contact with the sev-
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
ered elements of the coils.
George H. Crossley, Heart and Vascular Institute,
The likely mechanism of this fracture is the action
Vanderbilt University, 1215 21st Avenue North, Nash-
of connective tissue on the coils. The fractured ele-
ville,
ments then serve to disrupt other elements of the
[email protected].
Tennessee
37232-8802.
E-mail:
lead. Once the integrity of the coil is lost, a fulcrum mechanism may cause fracture of the pace/sense
KEY WORDS defibrillator, lead failure, subclavian crush
From the Vanderbilt University Heart and Vascular Institute, Nashville, Tennessee. Dr. Crossley has received speaking and consulting fees from Medtronic and Boston Scientific. Dr. Ellis has received consulting fees from Spectranetics; has received research support and consulting fees from Medtronic and Boston Scientific; and has served on the advisory boards of Medtronic and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 25, 2016; revised manuscript received May 18, 2016, accepted May 26, 2016.
George.