Letter Regarding the Article “Step‐by‐Step: Subclavian Venoplasty to Facilitate Cardiac Implantable Electronic Device Upgrade”
Year: 2026
Type: article
Abstract: We read with great interest the paper by Haq et al. [1] describing subclavian venoplasty in patients undergoing an upgrade of a cardiac implantable electronic device (CIED). Although often asymptomatic, lead-related venous obstruction is an increasingly recognized problem when an additional lead(-s) needs to be implanted in patients with a CIED. Several approaches have been described to address this challenge. Venoplasty has gained increasing attention and wider use, largely due to its safety and efficacy. We would like to provide some comments on the paper. The scope of the topic is broader than indicated by the title, as venous stenosis or occlusion may occur not only in the subclavian vein but also in the innominate vein and even the superior vena cava (SVC). Most techniques and cohorts reported in the literature [2], including the current paper, use access via the axillary or subclavian vein and employ standard peripheral intervention wires (hydrophilic 0.035 inch). However, this strategy presents two potential challenges. First, in cases of peripheral occlusions originating in the axillary vein, even when a peripheral axillary puncture is feasible, the short distance to the stenosis or occlusion may restrict wire and/or catheter manipulation. For this reason, we advocate peripheral access through the brachial vein in the upper arm as a default strategy [3]. Performing a central venogram close to the stenotic or occluded segment subsequently allows for more accurate delineation of the obstruction and planning of the procedure. Second, while a 0.035 inch hydrophilic wire can often cross subtotal stenoses, this is rarely possible in the setting of total occlusions, which frequently present with hard-to-penetrate proximal and distal caps. In such cases, we believe the only viable option is a wire escalation strategy, as established in coronary chronic total occlusion interventions, using dedicated 0.014 inch guidewires. We strongly support this stepwise approach, which combines materials, expertise, and techniques from interventional cardiology and radiology. When performed according to safety principles, this method can be readily applied in all catheterization laboratories that perform coronary interventions and device implantations. Lastly, we respectfully disagree with the two points raised in section “When to Abandon” (2.12). Using an alternative vascular access site typically entails employing the right pectoral approach in cases of left-sided stenosis, or vice versa. This strategy, however, carries a significant risk of SVC syndrome, particularly in patients with central venous stenosis or occlusion. With regard to the suggestion of symptom relief through open vascular surgery, accumulating evidence indicates that lead extraction followed by stenting and reimplantation through the stent represents the preferred strategy, especially in the context of SVC syndrome [4].
DOI: 10.1111/jce.70263
Authors: Erik Lipsic, Alexander H. Maass
Institutions: University Medical Center Groningen, University of Groningen
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7124272038