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?
Hover over an experts image to view their approach.
Dr. Nathan Taggart
Pediatric Interventional Cardiologist
Assistant Professor of Pediatrics
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
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
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
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