Transvenous Route Research Articles

An effective and safe alternative to epicardial pacemaker placement for permanent pacemaker implantation in a patient with mechanical tricuspid valve: stimulation of the left ventricle through the coronary sinus

Implantation of a transvenous endocardial pacemaker is contraindicated in patients with a mechanical tricuspid valve. An epicardial left ventricular pacemaker lead was placed by a transvenous route through the coronary sinus into the lateral cardiac vein in a 58-year-old woman with mechanical aortic, mitral, and tricuspid valves, for permanent pacing due to chronic atrial fibrillation with a slow ventricular rate accompanied by syncope. This lead was then connected to a single-chamber pacemaker. The patient had no problem in the following three months. Placement of an epicardial pacing lead through the coronary sinus provides a safe and effective pacing in patients with a mechanical tricuspid valve, thus obviating major cardiac surgery.

Transorbital Endovascular Embolization of Dural Carotid-Cavernous Fistula: Access to Cavernous Sinus through Direct Puncture: Case Examples and Technical Report

We present 2 cases of carotid-cavernous fistulas that failed multiple attempts at transarterial and transvenous embolization. Direct transorbital puncture for embolization was successful in curing the fistulas. The relevant anatomy and technique are reviewed. The first case is a 39-year-old man who presented with a 2-month history of worsening right-sided chemosis, proptosis, double vision, and progressive right eye vision loss. The second case is a 79-year-old woman with a 5-month history of right-sided chemosis and a 1-month history of complete left ophthalmoplegia. Cerebral angiography revealed an indirect carotid-cavernous fistula (CCF) in both patients, supplied by meningeal branches of the internal and/or external carotid arteries. After multiple unsuccessful attempts at transarterial and transvenous embolization, the CCFs were accessed via direct percutaneous transorbital puncture of the inferior and superior ophthalmic veins, respectively. The fistulas were then successfully occluded with a combination of Onyx and detachable coils. In rare cases in which more conventional transvenous and transarterial routes to a CCF have been exhausted, direct percutaneous transorbital puncture represents a viable means of achieving catheterization of the fistulous connection. In most cases, where a prominent arterialized superior ophthalmic vein is present, direct puncture represents a reasonable alternative to ophthalmologic cut-down procedures. Transorbital puncture of the inferior ophthalmic vein provides a direct route to the cavernous sinus in cases where the superior ophthalmic vein is atretic and inaccessible by direct surgical cut-down procedures.

Pediatric aneurysms and vein of Galen malformations

Pediatric aneurysms are different from adult aneurysms – they are more rare, are giant and in the posterior circulation more frequently than in adults and may be associated with congenital disorders. Infectious and traumatic aneursyms are also seen more frequently. Vein of Galen malformations are even rarer entities. They may be of choroidal or mural type. Based on the degree of AV shunting they may present with failure to thrive, with hydrocephalus or in severe cases with heart failure. The only possible treatment is by endovascular techniques – both transarterial and transvenous routes are employed. Rarely transtorcular approach is needed. These cases should be managed by an experienced neurointerventionist.

Direct Carotid-Cavernous Fistula following Intracavernous Carotid Aneurysm Treatment with a Flow-Diverter Stent

A 39-year-old woman presented with a right intra-cavernous carotid aneurysm measuring 1.76 cm×1.33 cm. The aneurysm was treated with a self-expandable flow-diverter stent. Follow-up MRI showed normal flow in the internal carotid artery with partial thrombosis of the aneurysmal sac. Two weeks later, the patient developed a right direct carotid-cavernous fistula. The fistula was treated by transvenous route. We concluded that rupture of a previously unruptured aneurysm can occur after treatment with a flow-diverter stent.

Evolution of treatment options for vein of Galen malformations

Vein of Galen aneurysmal malformations (VGAMs) continue to account for high morbidity and mortality rates in the pediatric population. Whereas in the past, mortality rates were nearly 100%, recent developments in endovascular embolization and improvements in neonatal care have improved prognoses. It is now possible that some patients can achieve normal neurological development following embolization of the VGAM. Access to the lesion can be gained via transarterial or transvenous routes. In this paper the authors review the pathophysiological characteristics of VGAM and discuss the evolution of treatment options. A PubMed literature search was performed for vein of Galen malformation treatment options, beginning in the 1970s. A total of 22 papers were reviewed in full, and outcome data for 615 patients from 1983 to 2010 were compiled. Articles were reviewed if they focused primarily on the treatment of VGAM and reported outcomes for at least 5 treated patients. Of the 265 patient outcomes reported between 1983 and 2000, 200 received endovascular therapy. Of these patients 72% had a favorable outcome, and a 15% mortality rate was found. Microsurgery was found to have an 84.6% mortality rate. Furthermore, 76.7% of untreated patients died. More recently, endovascular embolization has become the mainstay of VGAM treatment. Of the 350 patients assessed between 2001 and 2010, 337 were treated endovascularly, mostly via the transarterial approach. Of these patients, 84.3% were found to have good or fair outcomes, and a 15.7% mortality rate was found. Neonates had the worst clinical outcomes following endovascular treatment, with a 35.6% mortality rate, whereas infants and children had significantly better outcomes, with mortality rates of 6.5% and 3.2%, respectively. Endovascular embolization has considerably improved outcomes in patients with VGAM. In the past, the prognosis for patients with VGAM was dismal, and successful procedures were considered to be those that partially or completely obliterated the lesion, but did not necessarily improve the patient's symptoms. More recently, with the continued development and improvement of endovascular techniques, many patients are found to be neurologically normal on follow-up, and mortality rates have dropped substantially when compared with microsurgical treatment.

Transvenous occlusion of patent ductus arteriosus in 56 consecutive dogs

Objective Document safety and efficacy of transvenous catheter occlusion of patent ductus arteriosus (PDA) over a wide range of ductal and patient sizes. Animals, materials and methods Retrospective study of fifty-six consecutive dogs referred to Colorado State University with diagnosis of PDA. All cases utilized the transvenous approach, via the femoral vein. Occlusion was achieved using a coil (Flipper™) in dogs with PDA minimal dimension of ≤4 mm. Amplatzer ® duct occluder or Amplatzer ® vascular plugs were used in dogs with PDA minimal dimension >4 mm, or if a coil was unstable following deployment. Results Ductal occlusion was achieved using the transvenous route alone in 54/56 dogs (96.4%). Occlusion was achieved using detachable Flipper™ coils in 39/42 dogs (92.9%) in which coil occlusion was attempted, with 38/39 dogs (97.4%) requiring only a single coil. In 16 dogs, occlusion was achieved using an Amplatzer ® duct occluder or vascular plug. Post-procedure residual ductal flow was absent or only mild in 36/39 (92.3%) dogs in which it was assessed. Procedural mortality rate was 1.7%, and major complication rate 7.0%. Conclusion Transcatheter occlusion via a transvenous approach is a safe and effective method for treating PDA in dogs and is useful for small dogs (<2.5 kg).

Onyx embolization of carotid-cavernous fistulas

The authors conducted a study to determine the safety and efficacy of embolization of carotid-cavernous fistulas (CCFs) with the ethylene vinyl alcohol copolymer, Onyx. They prospectively collected data in all patients with CCFs who underwent Onyx-based embolization at their institution over a 3-year period. The type of fistula, route of embolization, viscosity of Onyx, additional use of coils, extent of embolization, procedural complications, and clinical follow-up were recorded. A total of 12 patients (5 men and 7 women who were age 24-88 years) underwent embolization in which Onyx was used. There were 1 Barrow Type A, 1 Type B, 3 Type C, and 7 Type D fistulas. Embolization was performed via a transvenous route in 8 cases and a transarterial route in 4 cases. Onyx 34 was used in all but 2 cases: a direct Type A fistula embolized with Onyx 500 and an indirect Type C fistula embolized with Onyx 18. Adjuvant embolization with framing coils was performed in 7 cases. All procedures were completed in a single session. Immediate fistula obliteration was achieved in all cases. Clinical resolution of presenting symptoms occurred in 100% of the patients by 2 months. Neurological complications occurred in 3 patients. One patient developed a complete cranial nerve (CN) VII palsy that has not resolved. Two patients developed transient neuropathies--1 a Horner syndrome and partial CN VI palsy, and 1 a complete CN III and partial CN V palsy. Radiographic follow-up (mean 16 months, range 4-35 months) was available in 6 patients with complete resolution of the lesion in all. Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.

Evolution of endovascular management of intracranial dural arteriovenous fistulas: Single center experience

We aim to focus on the treatment of intracranial dural arteriovenous fistulas (DAVF) with emphasis on the evolution of endovascular management at our center over the last 13 years. We also aim to highlight the present treatment strategy, considering all the embolic agents available with us. This is a retrospective study of 99 patients of DAVFs treated from December 1995 to March 2009. Seven patients were found to have spontaneous thrombosis when taken up for treatment. The other 92 patients underwent endovascular treatment through transarterial or transvenous routes using polyvinyl alcohol particles, glue, detachable platinum coils or injection onyx as embolic agents. The treatment strategies have evolved over a period of time with changing philosophies and availability of different embolic agents. Transverse- sigmoid and cavernous sinuses were the commonest sites of DAVFs. Intracranial hemorrhage was common presentation. Transarterial PVA embolization was performed in four patients, transarterial glue in 15, transvenous embolization in 33 and transarterial Onyx in 36. Direct puncture and packing of the sinuses was done in four patients. Cure was achieved in 80 out of 92 patients (cure rate of 87%). Patients who had Onyx embolization had cure rate of 92% (33 out of 36 patients). 14 complications were seen of which two were in the Onyx group. Embolization of DAVFs has evolved over the last decade and has become the treatment of choice with high cure rates and improved safety. We propose the use of Onyx as the embolic agent of choice in the treatment of DAVFs.

Study on inferior petrosal sinus and its confluence pattern with relevant veins by MSCT

To explore the anatomic route of inferior petrosal sinus (IPS) after going out of the cranium and its confluence patterns with internal jugular vein (IJV), anterior condylar vein (ACV) and lateral condylar vein (LCV), and to supply knowledge about typing of IPS-IJV junction, so as to provide reference evidence for evaluation of transvenous access route in the diagnosis and treatment of skull base and cavernous sinus lesions. In 120 patients, the IPS route and its confluence with IJV, ACV and LCV were shown by multi-planar reconstruction (MPR) and curve multi-planar reconstruction (CMPR). Combining with continuous thin slice, the IPS-IJV junction was further subdivided according to the level of IPS confluence with IJV and whether there is an anastomosis with sigmoid sinus (SS). Furthermore, the IPS length, venous diameter at IPS-IJV junction and IPS-SS communicating branch were determined and compared. Inferior petrosal sinus directly draining into jugular bulb (JB) or/and draining into JB after communication with SS was found in 28 sides (11.7%, pattern A); IPS draining into IJV at the level of exterior opening of hypoglossal canal in 114 sides (47.5%, pattern B); IPS draining into IJV in a lower extracranial level in 83 sides (34.6%, pattern C); IPS with multiple junctions draining into IJV near the jugular foramen in 12 sides (5.0%, pattern D); IPS directly draining into VVP in 1 side (0.4%, pattern E); IPS being absent in 1 side (0.4%, pattern F). IPS draining into VVP via ACV was seen in 218 sides, IPS draining into VVP via LCV in 100 sides and IPS directly draining into IJV in 14 sides. After going out of the cranium, IPS goes along with IJV for a relatively long distance in some cases. The IPS extracranial length over 40 mm was found in ten sides and the lowest level of IPS route was at the inferior margin of the fourth cervical vertebra. The venous diameter at the IPS-IJV confluence was 0.8-5.7 mm (mean 2.51 mm) and it was significantly larger on the right side than on the left (P = 0.01). However, there was no remarkable difference between male patients and female ones. Continuous thin-slice scanning by multislice spiral computed tomography in combination with MPR and CMPR can clearly show IPS route and its confluence with relevant veins, and determine the feasibility of procedures via IPS. Therefore, it can be used as an effective method for preoperative evaluation of IPS for diagnosis and treatment of skull base and cavernous sinus lesions by IJV access route.

Embolization of an Intracranial Dural Arteriovenous Fistula Using Ultrasound-Guided Puncture of a Pericranial Venous Pouch

Endovascular treatment of intracranial dural arteriovenous fistulas can be very challenging. Conventional endovascular treatment approaches include transarterial or transvenous access from the common femoral artery or vein, respectively. A novel approach is described for endovascular treatment of an aggressive type 4 dural arteriovenous fistula. This patient, who had recently suffered an associated intracranial hemorrhage, harbored a dural arteriovenous fistula involving his transverse dural venous sinus that did not allow for conventional transarterial or transvenous embolization routes. The clinical history and technical details are provided.

Development of a new model of transvenous thrombosis in the pig superior sagittal sinus using thrombin injection and balloon occlusion

To establish an experimental model of superior sagittal sinus (SSS) thrombosis using a transvenous route, and thrombin and balloon occlusion, in pigs. The SSS was catheterized transvenously in six pigs. Thrombin was injected into the pigs' SSS to induce thrombosis. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) confirmed successful SSS thrombosis. MRI and MRV were also used to observe the evolution of thrombus and accompanying brain parenchymal changes before thrombus induction postoperatively on Days 1, 3, and 7. The pigs were sacrificed for histological examination at the follow-up. SSS thrombosis was successfully achieved in all six pigs. On Day 1 postoperatively, MRV confirmed SSS thrombosis and MRI revealed brain edema in each animal. On Day 3, venous infarction was noted in two cases, one of which appeared to be hemorrhagic. On Day 7, MRV showed partial recanalization of the SSS in one pig. Brain edema was significantly relieved in four cases while, in two other cases, the extent of venous infarction was reduced. Histological examination confirmed SSS thrombosis in all animals, with recanalization in only one case. In two of the animals, bilateral parasagittal infarction was seen, including one with petechial hemorrhage. In the other four animals, bilateral parasagittal edema was observed. The development of an experimental model of SSS via the transvenous route is feasible in pigs using thrombin and balloon occlusion. This model closely resembles SSS thrombosis in humans, and can be applied in the clinical study of this phenomenon as well as in clinical therapeutic applications.

Onyx embolisation of cavernous sinus dural arteriovenous fistula via direct percutaneous transorbital puncture

The cavernous sinus dural arteriovenous fistulas of three patients were successfully embolised by using Onyx (Onyx Liquid Embolic System, MTI, Irvine, CA, USA) as the sole embolic agent, through direct percutaneous transorbital punctures of the cavernous sinuses. Our early experience suggests that this direct approach, coupled with the unique physical properties of Onyx, is a safe and effective alternative to treat cavernous sinus dural arteriovenous fistulas when the conventional transvenous routes are inaccessible.

Permanent Atrial Pacing Lead Implant Route after Fontan Operation

Atrial pacing is indicated for sinus node dysfunction (SND) after Fontan surgery; preferred lead implantation technique is debated. We compare outcomes of transvenous (TV) and epicardial (Epi) atrial lead implants in this population. Retrospective review of Fontan patients undergoing atrial lead implant between 1992 and 2007. Demographics, lead performance data, and outcomes were analyzed. 78 patients had 90 leads implanted: 25 via TV route and 65 via Epi route. Median follow-up was 1.6 years (TV) and 3.6 years (Epi). TV leads were implanted in older patients (23.1 vs 9.3 years, P < 0.001) and at longer intervals after Fontan (15.2 vs 4.9 years, P < 0.001). Pacing indication for most TV leads was SND, while Epi leads were also indicated for atrioventricular block. Acute complication rates were similar (8% TV vs 19% Epi, P = 0.23), but median hospital stay was shorter for TV (2 vs 5 days, P = 0.03). Thrombus was observed in five patients (two in TV; three in Epi), but no thromboembolic events were observed. Mean lead survival was similar (TV 9.9 vs Epi 7.8 years, P = NS). Energy threshold was lower at implant for TV leads (0.9 vs 2.2 microJ, P = 0.049), but similar at follow-up (1.2 vs 2.6 microJ, P = 0.35). Atrial sensing was unchanged over time for TV (2.2 to 2.1 mV, P = NS), but decreased for Epi (3.3 to 2.5 mV, P = 0.02). Compared to epicardial leads, transvenous atrial pacing leads may be placed in Fontan patients with lower procedural morbidity and equivalent expectation of lead performance and longevity.

In the field of cardiac resynchronization therapy is left ventricular pacing via the coronary sinus a mature technique

In the first reported case of cardiac resynchronization therapy (CRT) in 1994, left ventricular (LV) pacing was performed using an epicardial approach.1 The use of a lead inserted into a coronary sinus (CS) tributary vein to pace the LV was initially proposed in patients in whom right ventricular (RV) pacing could not be performed by a transvenous approach and later by Blackburn and Gibbs2 and Daubert et al. 3 for cardiac resynchronization. The CS approach was used rather than the epicardial one because it was less invasive and did not require general anaesthesia in very delicate patients, but this new technique involved several difficulties: (i) to catheterize the CS in a usually marked dilated heart; (ii) to reach a CS tributary vein to pace the LV; (iii) to insure lead stability into the vein. The transvenous route aims to reach the target vein with an acceptable pacing threshold and without phrenic nerve stimulation in order to obtain the best mechanical resynchronization. During the first years of experience with LV pacing via the CS, … *Corresponding author. Tel: +33 141 120712, Fax: +33 141 120715, Email: alonso{at}inparys.com

Successful Transarterial Embolization of a Barrow Type D Dural Carotid-Cavernous Fistula with Ethylene Vinyl Alcohol Copolymer (Onyx)

Endovascular occlusion via the transvenous route is the favored treatment method for dural carotid-cavernous fistulas (CCFs). Ethylene vinyl alcohol copolymer (Onyx), recently approved for treatment of arteriovenous malformations, has advantages over conventional liquid embolic agents in its nonadhesive nature, which allows for longer injections with decreased risk of catheter retention. We report the use of Onyx in the successful transarterial embolization of a dural CCF fed by arterial branches of the internal and external carotid arteries (Barrow type D) after multiple failed attempts to access the cavernous sinus transvenously. Transarterial Onyx embolization could be a valuable option in transarterial treatment of CCFs when venous access is difficult.

Endovascular transvenous embolization of sinus pericranii

Sinus pericranii (SP) is an abnormal communication between the intra- and extracranial venous drainage pathways. Treatment of this condition has mainly been recommended for reasons of cosmesis and prevention of hemorrhage. The authors report a novel endovascular transvenous route for definitive treatment of SP.

Video‐Assisted Thoracoscopic Implantation of the Left Ventricular Pacing Lead for Cardiac Resynchronization Therapy

To study the feasibility and efficacy of video-assisted thoracoscopic (VAT) placement of the left ventricular pacing lead for cardiac resynchronization therapy (CRT) where the conventional transvenous coronary sinus approach has failed. Seventeen patients underwent the VAT procedure. Indications for CRT were ischemic cardiomyopathy in six patients and nonischemic cardiomyopathy in 11. The procedure was performed under general anesthesia with single-lung ventilation. Three 2-cm incisions were used on the left chest wall to place the screw-in lead near the obtuse marginal arteries high on the lateral wall of the left ventricle (LV). The VATS approach was successful in 13/17 (76%) patients. Median procedure time was 75 minutes (range 55-135). A learning curve was observed that appeared to plateau at 75 minutes procedure time after four cases. Median length of hospital stay was 2 days (range 2-8) with one patient requiring intensive care. Satisfactory thresholds and impedances of 2.3 +/- 0.9 V/0.5 ms and 560 ohms, respectively, were achieved at mean follow-up of 226 days. All patients reported symptomatic benefit with reduction in New York Heart Association score from III preoperatively to II postoperatively. VAT placement of the epicardial pacing lead is feasible, safe, and efficacious. It should be considered in cases where the transvenous route has failed or as an alternative in prolonged or hazardous transvenous procedures.

Stenting the ductus arteriosus: Case selection, technique and possible complications

Ductal stenting is an attractive alternative to conventional shunt surgery in duct dependent congenital heart disease as it avoids thoracotomy and its related problems. With today's generation of coronary stents which have better profile, flexibility and trackability, ductal stenting may be achieved safely and with considerably less difficulty than previously described.As in Blalock-Taussig (BT) shunt, ductal stenting is indicated mainly in duct-dependent cyanotic lesions chiefly in the neonatal period. Unlike the Patent ductus arteriosus (PDA) as an isolated lesion, the ductus in cyanotic heart disease has a remarkable morphologic variability. The ductus tends to arise more proximally under the aortic arch, giving rise to a vertical ductus or occasionally it may arise from the subclavian artery. It also tends to be long and sometimes very tortuous, rendering stent implantation technically impossible. The ductus in these patients may also insert onto one of the branch pulmonary arteries with some stenosis at the site of insertion. The ductus in Tetralogy of Fallot with pulmonary atresia (TOF-PA) tend to exhibit these morphologic features and to a lesser degree in transposition of great arteries with ventricular septal defect and pulmonary atresia (TGA-VSD-PA) and the more complex forms of univentricular hearts. In the preliminary angiographic evaluation, it is important to delineate these morphologic features as the basis for case selection.Ductal stenting may be done by the retrograde femoral artery route or the antegrade transvenous route depending on the ductus morphology and the underlying cardiac lesion. The detailed techniques and essential hardware are described. Finally, major potential complications of the procedure are described. Acute stent thrombosis is the most serious and potentially catastrophic. Emergent treatment with thrombolytic therapy and mechanical disruption of thrombus are required. With proper case selection, appropriate technique and the right hardware ductal stenting provides reasonable short-medium term palliation in duct-dependent cyanotic heart disease.

The 59th Annual Meeting of the American Academy of Neurology, Boston, Massachusetts April 28-May 5, 2007

The 59th Annual Meeting of the American Academy of Neurology, Boston, Massachusetts April 28-May 5, 2007

Morphologic Evaluation of the Caudal End of the Inferior Petrosal Sinus Using 3D Rotational Venography

The inferior petrosal sinus (IPS) is the main transvenous access route used to examine or treat lesions involving the cavernous sinus. To carry out these procedures successfully, one must have a detailed knowledge of the anatomy of the venous system around the junction of the IPS and the internal jugular vein (IJV). Eighty-three sides in 63 patients (26 men, 37 women; mean, 56.5 years of age) were examined by using 3D rotational venography (3DRV). The drainage patterns of the IPS could be classified into the following 6 types, with emphasis on the level of IPS-IJV junction: type A, the IPS drains into the jugular bulb in 1/83 sides (1.2%); type B, the IPS drains into the IJV at the level of the extracranial opening of the hypoglossal canal in 29/83 sides (34.9%); type C, the IPS drains into the lower extracranial IJV in 31/83 sides (37.3%); type D, the IPS forms a plexus and has multiple junctions to the IJV near the jugular foramen in 5/83 sides (6.0%); type E, the IPS drains directly into the vertebral venous plexus (VVP) with no connection to the IJV in 3/83 sides (3.6%); and type F, the IPS is absent in 14/83 sides (16.9%). Each type is also characterized by the way of anastomosis with the VVP. This classification seemed to be rational from the embryologic viewpoint, and it may be useful in establishing treatment strategies that involve endovascular manipulation via the IPS.