ABC | Volume 111, Nº5, November 2018

Original Article Usefulness of Preoperative Venography in Patients with Cardiac Implantable Electronic Devices Submitted to Lead Replacement or Device Upgrade Procedures Caio Marcos de Moraes Albertini, 1 Katia Regina da Silva, 1 Joaquim Maurício da Motta Leal Filho, 1 Elizabeth Sartori Crevelari, 1 Martino Martinelli Filho, 1 Francisco Cesar Carnevale, 2 Roberto Costa 1 Instituto do Coração (InCor) - Faculdade de Medicina da Universidade de São Paulo, 1 São Paulo, SP – Brazil Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, 2 São Paulo, SP – Brazil Mailing Adress: Roberto Costa • Av. Dr. Enéas de Carvalho Aguiar, 44, Postal Code 05403-900, Cerqueira César, São Paulo, SP - Brazil E-mail: rcosta@incor.usp.br Manuscript received October 02, 2017, revised manuscript May 07, 2018, accepted June 12, 2018 DOI: 10.5935/abc.20180164 Abstract Background: Venous obstructions are common in patients with transvenous cardiac implantable electronic devices, but they rarely cause immediate clinical problems. The main consequence of these lesions is the difficulty in obtaining venous access for additional leads implantation. Objectives: We aimed to assess the prevalence and predictor factors of venous lesions in patients referred to lead reoperations, and to define the role of preoperative venography in the planning of these procedures. Methods: From April 2013 to July 2016, contrast venography was performed in 100 patients referred to device upgrade, revision and lead extraction. Venous lesions were classified as non-significant (< 50%), moderate stenosis (51-70%), severe stenosis (71-99%) or occlusion (100%). Collateral circulation was classified as absent, discrete, moderate or accentuated. The surgical strategy was defined according to the result of the preoperative venography. Univariate analysis was used to investigate predictor factors related to the occurrence of these lesions, with 5% of significance level. Results: Moderate venous stenosis was observed in 23%, severe in 13% and occlusions in 11%. There were no significant differences in relation to the device side or the venous segment. The usefulness of the preoperative venography to define the operative tactic was proven, and in 99% of the cases, the established surgical strategy could be performed according to plan. Conclusions: The prevalence of venous obstruction is high in CIED recipients referred to reoperations. Venography is highly indicated as a preoperative examination for allowing the adequate surgical planning of procedures involving previous transvenous leads. (Arq Bras Cardiol. 2018; 111(5):686-696) Keywords: Pacemaker, implantable defibrillators, phlebography, venous stenosis, extraction of leads, risk factors. Introduction Venous obstructions frequently occur in patients with transvenous cardiac implantable electronic devices (CIED), with an estimated 14 to 64% prevalence. 1-11 Those lesions are mostly asymptomatic, although visible collateral circulation in the thoracic region is usually found. Although deep venous thrombosis, pulmonary thromboembolism, or superior vena cava syndrome were found in 1.6 to 12% of the cases, the difficulty in gaining access to implant new additional leads or other types of transvenous devices has been the main consequence of those lesions. 12-16 Recent studies have shown an increase in the number of reoperations in which it is necessary to handle the intravascular territory with leads previously implanted. 17-23 The increase in this type of procedure is due to three main factors: (1) patients’ increasing longevity, which is directly related to the longer period of time leads remain in the territory and, consequently, to a greater chance of dysfunction of the stimulation system’s components; (2) an increase in comorbidities leading to an increase in the occurrence of infectious complications, whose treatment necessarily requires the complete CIED removal 17-23 and (3) an increasing prevalence heart failure and , consequently, of the need to upgrade from the conventional pacemaker to more advanced modes, such as implantable cardioverter ‑ defibrillator (ICD) , or cardiac resynchronization therapy (CRT), which require the implantation of additional leads . 24-27 Digital subtraction venography provides excellent characterization of the venous anatomy and has been deemed the gold standard for studying venous lesions in CIED patients. 11,28-30 Although other imaging techniques are used for the same purpose, such as Doppler ultrasonography or contrast 686