Provocative Cases -> Teaching Case Reports D-PO02 - Poster Session II (ID 47) Poster

D-PO02-061 - Management Of Patients With Interrupted Inferior Vena Cava Requiring Electrophysiology Procedures (ID 998)


Background: Interrupted inferior vena cava (IVC) is a rare anomaly that complicates access for electrophysiology (EP) procedures.
Objective: Determine the feasibility of alternative access.
Results: Five patients with interrupted IVC were included (Table). Individualized access strategies were employed for each case. All cases were performed under general anesthesia.
In patient 1 accessory pathway ablation was completed using left axillary vein and right internal jugular vein (IJ) access. For patient 2, right IJ and right basilic vein access were obtained for slow pathway ablation. For patients 3 and 4 pulmonary vein isolation and cavo-tricuspid isthmus ablation were performed using right IJ and transhepatic vein access. Transseptal puncture, mapping, and ablation were then performed in a standard fashion. For patient 5’s WATCHMAN implant, femoral venous access was obtained and venography identified the access path (L renal vein to hepatic vein to IVC). The procedural end points were achieved in all patients.
Protamine was infused with manual compression in all patients. For patients 3 and 4 with transhepatic access, hemostasis was achieved by the application of Gel-Foam pledgets in patient 3, and a 10 x 7 mm Amplatzer vascular plug followed by several Nester embolization coils in patient 4. Patient 5 developed a pericardial effusion requiring pericardiocentesis. None of the patients had recurrence or further complications during follow up of 30 - 626 days.
Conclusion: Alternative access approaches are feasible in patients with interrupted IVC. With adequate preprocedure planning and expertise, they can be performed safely and may obviate the need for surgery.
Table. Patient and procedural characteristics
Patient numberAge/GenderDiagnosisProcedurePlanned ApproachAccessCathetersFollow-up (days)
140/FWPWEPS + RFATransjugular-transseptalLeft axillary (8F); Right IJ (8F); Right IJ (9F)CS catheter; Transseptal access; ICE178
264/FAVNRTEPS + RFATransjugularRight basilic (8F); Right IJ (8F); Right IJ (8F)
Quadripolar catheter; CS catheter; Ablation catheter257
364/MAtrial fibrillationPVI + CTITranshepatic-transseptalHepatic vein (12F); Right IJ (8F)Transseptal access; CS catheter530
444/FAtrial fibrillationPVI + CTITranshepatic-transseptalHepatic vein (14F); Right IJ (8F)Transseptal access; CS catheter30
588/FAtrial fibrillationWATCHMANFemoral-renal-hepatic-transseptalRight femoral vein (16F)Transseptal access for WATCHMAN626