M.O. Schrage, C. Lenz, L. Bruch, B. Keweloh

Klinik für Innere Medizin / Kardiologie Unfallkrankenhaus Berlin Berlin, Germany


Introduction: Coronary vein dissection can complicate implantation of left ventricular transvenous leads for cardiac resynchronization therapy (CRT), oftentimes forcing an abortion of the procedure. We report a case of successful revascularization of a complete thrombotic occlusion of a coronary vein by stent implantation, followed by successful lead implantation.
Case Report : A 60 year old male with severe ischemic cardiomyopathy and a history of coronary artery bypass grafting and resection of a left ventricular (LV) aneurysm underwent implantation of a CRT-D-System at our institution. After uncomplicated intubation of the coronary sinus, occlusion venography caused an immediate coronary sinus dissection extending to the only target vessel for LV lead implantation (Img. 1a). The dissection could be crossed with a wire, but the LV lead (Acuity Spiral S, Boston Scientific) could not be advanced into the desired position due to thrombus formation and proximal tortuosity of the target vein. Attempts to remove the thrombotic material by venoplasty and improving backup with a third-generation sheeth ultimately lead to a complete proximal occlusion of the vein (Img. 1b). After deployment of a bare metal stent (Integrity 3,5x22mm, Medtronic; Image 1 c-d), the vein was fully patent again (Img. 1e), allowing for swift placement of the lead.
Conclusions: Coronary stents are being used more and more to overcome certain challenges in CRT implantation, be it to stabilize leads or to treat dissections. To our knowledge, this is the first report of a stent application to treat a complete coronary vein occlusion.

Figure 1.