The pre procedural venogram showed total occlusion
The pre-procedural venogram showed total occlusion of the left BCV and the formation of an acute angle between the right BCV and SVC caused by tuberculosis-induced lung destruction (Fig. 1A and B). We adopted a right-sided venous approach via the right subclavian vein (SCV) for a single chamber. Initially, the usual maneuver of inserting a guide-wire through the right BCV into the SVC was impossible because of the acute angle (Fig. 1A). However, we successfully inserted a peel-away sheath into the SVC using an angled Autophagy Compound Library guide-wire (TERUMO; Terumo Corp, Tokyo, Japan). Despite this, the ventricular lead (ENDOTAK RELIANCE G4-SITE; Boston Scientific, Natick, MA) could not be advanced beyond the acute angle, and fluoroscopy revealed that the ordinary peel-away sheath had kinked at that point (Fig. 1C). We then replaced the ordinary peel-away sheath with a 10 Fr/24-cm flexible coiled sheath (Arrow-Flex; Arrow International, PA, USA), after first removing its hemostatic valve. This corrected the acute angle between the BCV and SVC allowed the ventricular lead to advance easily into the SVC (Fig. 1D). Subsequently, the coiled sheath was carefully cut and separated from the ventricular lead using scissors. We successfully implanted the defibrillator (Generator: TELIGEN VR 4-SITE; Boston Scientific, Natick, MA) using the flexible coiled sheath for correcting the acute angle between the BCV and SVC. The results of lead condition were a pacing threshold of 0.6V, a sensing R-wave of 10.1mV, and lead impedance of 555Ω. At the 3-month follow-up, the lead profile parameters were not significantly different from the initial measurements.
Discussion It is important to consider anatomic findings when deciding whether a left or right BCV approach to the right ventricle should be used for device implantation. Successful intracardiac device implantation has previously been reported in patients with congenital anomalies such as persistent left SVC and right SVC atresia [1–3]. Previous reports have demonstrated that anomalous BCV is uncommon, accounting for approximately 0.2–1% of congenital cardiovascular anomalies. However, anatomical deformities, induced by a disease such as destructive lung or pneumonectomy, are an uncommon finding at the time of intracardiac device-lead implantation. In addition, chronic post-tuberculosis inflammation results in various complications, including vascular distortion [4,5] However, there are few reports in the literature of successful lead insertion into congenital or acquired unusual vasculature.
Conflict of interest