Tough Calls: Case 2

SVC and Superior Baffle Occlusion in a Patient Who Requires RESYNC ICD

37-year-old gentleman had recently been admitted with decompensated heart failure. His inotropes have not been weanable.

His anatomy is post Mustard repair of the D-TGA. He has New York Heart Association class III-IV heart failure. He is known to have severe RV systolic dysfunction with severe TR. He is not fit to be a transplant or VAD candidate. He is proposed for BI-V pacing. You are asked to open the superior baffle, which is occluded and decompressed by the azygous. How would you do it?

Expert Approaches

Hover over an experts image to view their approach.

MD, FSCAI
 
Dr. Nathan Taggart

Pediatric Interventional Cardiologist 
Assistant Professor of Pediatrics
Mayo Clinic 
  • Start with simultaneous angio from above and from below the obstruction to determine the length of artresia. I would use a standard Brockenbrough needle from the SVC  and frequent biplane angios to ensure I am headed in the right direction. 

  • Once continuity is created, pass a V18 wire from above the through needle and snare from below. Dilate the tract if necessary with a small diameter balloon +/- cutting balloon, enough to pass a 12 Fr Mullins.

  • Stent baffle with a CP covered stent, re-dilate with high-pressure (Atlas) as needed.   

•SVC and IVC access and simultaneous angiograms obst. Site

•TS needle to puncture the site, advance wire and may need to be snared if catheter cannot be advanced

•Stent

Dr. Zahid Amin
MD, FSCAI, FAHA, FAAP
 
William B. Strong Chair & Professor & Section Chief Division of Pediatric Cardiology
Children's Hospital of Georgia, Augusta University

Two Options:

1) Recanalise and reconstruct SVC baffle with stents (preferred approach)

2) Cross and balloon only such that can deliver a sheath across baffle so EP colleague can deliver pacing wire (s) at the same sitting

  • Access from above (R jugular) and below (femoral vein). Create roadmap with simultaneous injections above and below (pigtail injection / inferior stump of SVC)

  • Guide catheter from jugular access (6F MP or JR4)

  • Probe with coronary wire  (workhorse wire  Sion blue, or jacketed wire) with a microcatheter for support (eg Corsair 135cm / Finecross). 

  • Confident of position before follow with microcatheter or balloon.  Best option is to snare from below (eg EnSnare 12-20 / large gooseneck) 

  • Sequential balloon dilation - if on coronary wire, start with 3.0mm balloon. Then dilate up to 6mm.

  •  Further dilate with 10mm balloon 

  • Covered stent preferable (eg CP 8zig covered stent) and post dilate as needed. 

Dr. William Wilson
MBBS, PhD, FACC
 
Consultant Cardiologist at Royal Melbourne Hospital
  • Superior limb baffle obstruction in d-trans mustard

  • Right IJ and right femoral vein access

  • Angio SVC & RA to define distal “cap” and entrance

  • Use a peripheral CTO approach (Navicross and angled stiff glidewire from

  • above to start, progress to straight stiff glide)

  • Advance navicross over glide and exchange for stiff wire (Amplatz ES)

  • Serial balloon dilations with peripheral balloons (Charger)

  • Place iCast of Viahban VBX balloon expandable covered stent to finish

Dr.John Carroll
MD, FACC, MSCAI
 
Professor of Medicine, University of Colorado Denver
Director of Interventional Cardiology

I would access the femoral vein, the SVC and try to recanalize the occluded area. If successful, I would stent it to open the occlusion. I would use coronary occlusion wires, alternatively, use radiofrequency to recanalize. For biventricular pacing, I would place one lead after I recanalize the occluded vein.

Dr. Ziyad Hijazi
Professor of Pediatrics & Medicine, Weill Cornell Medicine
Chair, Department of Pediatrics and Director, Sidra Cardiac Program

 

•Access RIJV and femoral vein.

•Angiography (potentially simultaneous) of the superior and inferior baffles to outline the occlusion anatomy

•Consideration for pre-cath CT/MRI versus 3D rotational angiography to delineate the intracardiac and extracardiac anatomy and distances

•Recanalization of superior baffle using stiffer wires, CTO wires, RF wire or transseptal needle (likely from RIJV toward the atrium)

•Once across perform successive balloon dilation if very short distance and then stent implantation. Need to consider covered stent implantation depending on anatomy and certainly have available if planning on using an uncovered stent

Dr. Matthew Crystal
MD, FACC, FSCAI
 
New York-Presbyterian & Morgan Stanley Children's Hospital
Assistant Professor of Pediatrics, Columbia University Medical Centre

Imagine how you would work through each case. What equipment would you select and what would you do first? After having a go at it, see what our panel would do in the same situation. This exercise highlights the many possible approaches to a difficult problem. By seeing what others would do after thinking it through yourself, you will gain an understanding of the spectrum of approaches to a problem.