ABC | Volume 111, Nº5, November 2018

Original Article Albertini et al The role of preoperative venography in reoperations Arq Bras Cardiol. 2018; 111(5):686-696 1. Mond HG, Crozier I. The Australian and New Zealand cardiac pacemaker and implantable cardioverter-defibrillator survey: calendar year 2013. Heart Lung Circ . 2015;24(3):291-7. 2. Oginosawa Y, AbeH, Nakashima Y. The incidence and risk factors for venous obstruction after implantation of transvenous pacing leads. Pacing Clin Electrophysiol. 2002;25(11):1605-11. 3. Costa SS, Scalabrini Neto A, Costa R, Caldas JG, Martinelli FilhoM Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study. Pacing Clin Electrophysiol. 2002;25(1):1301-6. 4. Lickfett L, Bitzen A, Arepally A, Nasir K,Wolpert C, Jeong KMet al. Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography in patient presenting fortheirfirstelectiveICDgeneratorreplacement. Europace. 2004;6(1):25-31. 5. Van Rooden CJ, Molhoek SG, Rosendaal FR, Schalij MJ, Meinders AE, Huisman MV. Incidence and risk factors of early venous thrombosis associated with permanentpacemakerleads. JCardiovascElectrophysiol. 2004;15(11):1258-62. 6. Rozmus G, Daubert JP, Huang DT, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. J Interv Card Electrophysiol. 2005;13(1):9-19. References looked for. In this respect, we suggest maintaining dynamic venography images, which allow following the iodinated contrast path. Often enough, when the contrast passes exclusively through the collateral circulation, it fully fills up the blood vessel lumen soon after the critical lesion, which prevents it from being detected in still images. The high rate of patients with severe or occlusive lesions observed in this study, which agrees with the data in the literature, evidenced the importance of venography for surgical planning. In cases where significant venous lesions could not be identified, the surgical team were able to plan a procedure in which deactivated leads should (or should not) be extracted by considering solely factors such as patient age or the number of leads that would remain in the venous territory. On the other hand, in patients where moderate lesions were observed, the medical team could plan which leads should be extracted in order to avoid an overpopulation of leads that could worsen obstructions. And, finally, in the cases where severe or occlusive venous lesions were observed, the knowledge of the venous anatomy was of essence to plan the surgery, since it raises the possibility of using the ipsilateral jugular vein or the need of extracting leads to gain proper access. Since causes aremultifactorial, the literature is controversial as to defining predictive factors of thromboembolic complications in CIED patients. 2-11-36-37 In this respect, the absence of risk factors for venous lesions found in this study sample confirms the importance of preoperative venography in patients requiring lead reoperations, since it was not possible to identify any subgroup of individuals less subject to venous obstructions. Study Limitations Although this study is part of a prospective registry derived from medical practice, due to the non-inclusion criteria used, our conclusions cannot be extended to children, to individuals over 90 years of age and to those with renal dysfunction with serum creatinine over 1,5 mg/dL. As to the rate of venous alterations found and their predisposing factors, this analysis has the same limitations as other cross-sectional studies, as they were assessed at a particular time. Conclusions The high prevalence of severe obstructions or venous occlusions in CIED patients makes a transvenous implant of new leads difficult in a considerable number of patients. Sometimes, using non-conventional techniques, such as the extraction of leads to achieve access, can be mandatory. The lack of predisposing factors and the absence of clinical signs of venous obstruction, which occurs in most patients with severe or occlusive lesions, can hinder the planning of a surgery. Thus, digital subtraction venography is quite useful to define a surgical strategy in operations for lead revision or upgrade procedures. The finding of collateral veins in this exam has a high predictive value for diagnosing severe and occlusive lesions. Author contributions Conception and design of the research and Writing of the manuscript: Albertini CMM, Silva KR, Costa R; Acquisition of data: Albertini CMM, Leal Filho JMM, Crevelari ES; Analysis and interpretation of the data: Albertini CMM, Silva KR, Leal Filho JMM, Costa R; Statistical analysis: Silva KR; Critical revision of themanuscript for intellectual content: Albertini CMM, Silva KR, Martinelli Filho M, Carnevale FC, Costa R. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding This study was funded by FAPESP and CAPES. Study Association This article is part of the thesis of Doctoral submitted by Caio Marcos de Moraes Albertini, from Instituto do Coração – Faculdade de Medicina da Universidade de São Paulo. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Análise de Projetos de Pesquisa (CAPPesq) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo under the protocol number 0730/11. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 694