Venous Occlusion after Transvenous Pacemaker Implantation—Is There a Role for New Oral Anticoagulants?

Abstract

The use of new oral anticoagulants (NOACs) in numerous scenarios may be very interesting although their use always requires thorough evaluation regarding risks and benefits based on an in-depth understanding of each patient's comorbidities. Their perioperative use also requires further study [1][2][3][4][5]. We would like to focus the attention on a possible interesting use of NOACs. Central venous occlusions in pacing patients are often asymptomatic [6,7] due to the development of an adequate venous collateral circulation, but they can cause more difficulties in patients needing a device revision/upgrade/extraction requiring advanced tools and more time [6,8]. So far several pacing venous occlusions have been described, including superior vena cava (SVC) occlusion [9][10][11] [18] with risk factors such as diabetes, most frequently, followed by smoking, hypertension, obesity with a body mass index ≥30, history of acute myocardial infarction, chronic obstructive pulmonary disease and history of congestive cardiac failure (15 %) and responding to anticoagulation therapy while antiplatelets were not found protective [18]. Also, atrial fibrillation, foreign body-type reaction, and hypercoagulability have been suggested as possible mechanisms of pacing venous thrombosis [19]. Notably, implantable cardioverter defibrillators leads, after a long dwell-time, have been found affected by fibrous adherences uniformly distributed along the lead course and careful lead selection is recommended at the time of implantation to prevent adherences [20]. We usually search to remove the preexisting electrodes with a percutaneous approach, but if the adhesions between the leads and the venous wall cannot be gone over, in our opinion the surgical strategy is often mandatory [21][22][23]. Nowadays prevention of pacing venous occlusions represents an increasingly serious challenge as well its optimal management. Furthermore, perioperative lead extraction management varies between extraction centers, and no clinical guidelines [24] have focused on the need for anticoagulation. Nevertheless, routine peri-and postoperative anticoagulation has been advocated as a means to prevent vein occlusions including pulmonary embolism [25,26]. We think that NOACs may find a possible application in this emerging clinical scenario. Additional researches are needed and the journey of NOACs could be longer than expected.Acknowledgments Author contributions: Giuseppe Mario Calvagna prepared the references; Salvatore Patanè wrote the work.

Cardiac rehabilitation in pacing venous occlusions

“…Nowadays the need of cardiac rehabilitation in pacing venous occlusions is an increasing scenario and it represents a serious challenge as well as its optimal management ranging among anticoagulation, percutaneous stenting in combination with angioplasty, thrombolytic treatment, and multimodality therapy involving catheter directed thrombectomy and thrombolysis with percutaneous angioplasty and short course of anticoagulation. Furthermore, perioperative lead extraction management varies between extraction centers, and no clinical guidelines [84,97] have focused on the need for anticoagulation nevertheless routine peri-and post-operative anticoagulation have been advocated as a means to prevent vein occlusions including pulmonary embolism [84,98,99]. Rehabilitation in pacing venous occlusions is a difficult work needing a collaborative vision of a multi-disciplinary treatment http://dx.…”

“…A computational method studying pacing blood flow changes evidenced stasis increase at locations between the leads and along the surface of the vessels closest to the leads corresponding to regions at known thrombosis risk [83]. Central venous occlusion in pacing patients is often asymptomatic [80][81][82][83][84] due to development of an adequate venous collateral circulation but can cause more difficulties in patients needing of device revision/upgrade/extraction requiring advanced tools and more time [80][81][82][83][84]. Several pacing venous occlusions have also been described including superior vena cava (SVC) occlusion [84][85][86][87], subclavian vein occlusion [88,89], axillary vein occlusion [90], inferior vena cava (IVC) occlusion [91], subtotal innominate vein occlusion [92], and internal jugular vein occlusion [93].…”

“…Central venous occlusion in pacing patients is often asymptomatic [80][81][82][83][84] due to development of an adequate venous collateral circulation but can cause more difficulties in patients needing of device revision/upgrade/extraction requiring advanced tools and more time [80][81][82][83][84]. Several pacing venous occlusions have also been described including superior vena cava (SVC) occlusion [84][85][86][87], subclavian vein occlusion [88,89], axillary vein occlusion [90], inferior vena cava (IVC) occlusion [91], subtotal innominate vein occlusion [92], and internal jugular vein occlusion [93]. Moreover permanent pacemaker-related upper extremity deep vein thrombosis has been found [94] having risk factors like diabetes, most frequently, followed by smoking, hypertension, obesity with body mass index ≥30, history of acute myocardial infarction, chronic obstructive pulmonary disease and history of congestive cardiac failure (15%) and responding to anticoagulation therapy while antiplatelets were not found protective [94].…”