PO-707-08 ANTIDROMIC LEFT PERICARDIOPHRENIC VEIN ACCESS FOR DEPLOYMENT OF A PHRENIC NERVE STIMULATOR: LESSONS LEARNED FROM COMPLEX CORONARY SINUS LEAD IMPLANTATION

Abstract

Left pericardiophrenic vein (PPV) access is required to deploy over-the-wire phrenic nerve stimulator leads for implantable sleep apnea therapy devices. Coursing along the left lateral aspect of the pericardium, the left PPV is accompanied by the left phrenic nerve and terminates superiorly at the left brachiocephalic vein (BCV) and inferiorly at the left inferior phrenic vein. A superior approach may be complicated by congenital atresia, tortuous anatomy, or iatrogenic dissection. We report a novel approach to PPV access using retrograde wire externalization and antidromic lead placement derived from complex coronary sinus (CS) access techniques. Recognize techniques for complex vascular access for phrenic nerve stimulators and cardiac implantable electronic devices (CIED). The right chest was prepared for subclavian vein access and pre-pectoral generator implant. A 7 French (Fr) delivery sheath and inner 5 Fr Merit CS vertebral vein selector were used to engage the left BCV. Contrast angiography and a 0.014 mm angioplasty wire were used to identify the PPV. Repeated attempts to engage the tortuous vein were associated with proximal dissection. An alternative approach with inferior PPV access was selected. The sheath and vein selector were positioned within the left hepatic vein and the left phrenic vein for angiography. The angioplasty wire was advanced retrogradely into the PPV and left subclavian vein followed by an additional support wire. A separate 7 Fr sheath was placed in the right subclavian vein and a 4 Fr snare was used to secure and externalize the distal angioplasty wire. The wire was used as a rail to advance the phrenic nerve stimulator anterogradely into the PPV. Lead deployment was successful and phrenic nerve stimulation thresholds were satisfactory. Antidromic posterolateral cardiac vein access has been well described for complex coronary sinus lead implantation. The technique may be applied to extracardiac vascular anatomy for challenging PPV lead implantation. This case highlights the technical expertise and anatomical familiarity needed to optimize cardiac implantable electronic device implantation.