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1

A rare vascular anomaly in the form of double left brachiocephalic vein detected incidentally during cardiac implantable electronic device (CIED) placement

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Steckiewicz R., Swieton E. B., Stolarz P.
Folia Morphologica
|
2018
|
tom 77
|
nr 1
The growing number of transvenous cardiac implantable electronic device (CIED) implantation procedures helps detect rare vascular anomalies. Genetic disturbances in vascular development can produce systemic vein anomalies, including the left brachiocephalic vein (BCV). BCV anomalies commonly coexist with a persistent left superior vena cava (PLSVC), detected in 0.3–0.5% of the general population. The three known anatomical variations of PLSVC are two variations involving a BCV bridge and the third with BCV agenesis. BCV anomalies occur in 1% of patients with congenital heart defects, whereas the estimated proportion of BCV anomalies in the population with no cardiovascular symptoms is below 0.4%. A rarely observed, and thus rarely reported, BCV variation is a double left BCV, with the additional vessel typically found inferior and posterior to the ascending aorta prior to draining into the superior vena cava. This case report presents a previously unreported variation of double left BCV, with both vessels coursing parallel to each other, superior to the aortic arch. (Folia Morphol 2018; 77, 1: 161–165)
2

Altered topography of systemic veins following lung tissue resection: the effect on de novo cardiac implantable electronic device implantation

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Steckiewicz R., Swieton E. B., Rowinska-Berman K., Stolarz P.
Folia Morphologica
|
2017
|
tom 76
|
nr 2
Venous anomalies discovered on cardiac implantable electronic device (CIED) implantation may hinder both the insertion of cardiac leads and the selection of their optimal intraventricular placement. Such venous anomalies may be a result of congenital vascular defects, e.g. anomalies of the foetal venous system, or be a consequence of earlier cardio- or thoracosurgical procedures. In the case of the latter, the extent of morphometric changes to mediastinal structures may depend on the extent of prior lung tissue resection. This paper presents 3 cases of CIED implantation procedures performed in patients with systemic veins topographically and morphometrically altered post lung surgery. (Folia Morphol 2017; 76, 2: 322–325)
3

Clinical implications of cephalic vein morphometry in routine cardiac implantable electronic device insertion

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Steckiewicz R., Swieton E., Stolarz P., Grabowski M.
Folia Morphologica
|
2015
|
tom 74
|
nr 4
Background: Morphometric parameters of the venous vasculature constitute an important aspect in successful cardiac implantable electronic device (CIED) insertion. The purpose of this study was to present morpho-anatomical variations of the cephalic vein (CV) and their effect on the course of CIED implantation procedures, based on the patients from our centre. Materials and methods: We analysed contrast venography results obtained during first-time lead placement. Venography was indicated in the cases of problematic lead introduction with either the CV cutdown or axillary/subclavian vein puncture techniques. The 214 cases of venography (15%) performed out of 1425 first-time lead placement in the period 2011–2013 were divided into 9 subgroups according to the most commonly observed CV variations of similar morpho-anatomical features that limited the use of the CV cutdown technique for lead insertion. Results: The following CV morphometric parameters were found to be unfavourable in terms of lead placement: CV diameter of ≤ 1 mm (18%), sharp curvature of the terminal CV segment as it joined the axillary vein (14%), terminal CV bifurcation (9%), additional CV branches (7%) or tributaries (7%), stenoses (5%), sharply winding course (5%), single CV with a supraclavicular course (4%). Conclusions: The radiographic records obtained during the procedures allowed us to assess the prevalence of those atypical CV variations in our study group, with graphic presentation of characteristic types and sporadically reported CV variations. (Folia Morphol 2015; 74, 4: 458–464)
4

Selected clinical challenges of a supraclavicular cephalic vein in cardiac implantable electronic device implantation

100%
Swieton E. B., Steckiewicz R., Grabowski M., Stolarz P.
Folia Morphologica
|
2016
|
tom 75
|
nr 3
Background: Supraclavicular variations of the cephalic vein (CV) are detected sporadically. A somewhat more common finding is a CV variation with the typical course of the main vessel but with an additional supraclavicular branch, called the jugulocephalic vein (JCV). The aim of the study was to detect supraclavicular CVs or JCVs via intra-operative venography as well as assess their effects on primary and later revision cardiac implantable electronic device (CIED) procedures in our patients. Materials and methods: We analysed venographic images obtained during CIED procedures at our centre between 2011 and 2015. Out of the 324 venographies conducted during first-time CIED implantation, we identified 14 showing either a supraclavicular course of the CV itself or a persistent JCV. Among revision procedure venographies, we identified 1 case of pertinent CV variations. These vessels had been morphometrically altered by previous medical interventions. Results: Based on topography and morphometric parameters, we identified three anatomical variations of supraclavicular vessels: 2 cases of a supraclavicular CV and 12 cases of an infraclavicular CV accompanied by a persistent supraclavicular JCV (with the diameter larger than that of the main CV in 5 cases and smaller in 7 cases). In 2 cases the enlarged diameter of the JCV was probably due to increased collateral venous flow resulting from thrombotic lesions in the subclavian vein. Conclusions: Supraclavicular CV variations are rare. Nonetheless, they may significantly affect both first-time and later revision CIED procedures. The presence of a supraclavicular vein is an indication for diagnostic venography in the area of the clavipectoral triangle before the CIED procedure. (Folia Morphol 2016; 75, 3: 376–381)
5

Vasoconstrictive responses of the cephalic vein during first-time cardiac implantable electronic device placement

100%
Steckiewicz R., Swieton E. B., Bogdanska M., Stolarz P.
Folia Morphologica
|
2018
|
tom 77
|
nr 3
Background: During cardiac implantable electronic device (CIED) implantation procedures cardiac leads have been mostly introduced transvenously. The associated injury to the selected vessel and adjacent tissues may induce reflex vasoconstriction. The aim of the study was to assess the incidence of cephalic vein (CV) vasoconstriction during first-time CIED implantation. Materials and methods: Of the 146 evaluated first-time CIED implantation procedures conducted in our centre in 2016, we selected those during which CV vasoconstriction was recorded. We focused on the stage of the procedure involving CV cutdown and/or axillary vein (AV)/subclavian vein (SV) puncture for lead insertion. Only cases documented via venography were considered. Results: Vasoconstriction was observed in 11 patients (5 females and 6 males, mean age 59.0 ± 21.2 years). The presence of this phenomenon affected the stage of CIED implantation involving cardiac lead insertion to the venous system, in severe cases, requiring a change of approach from CV cutdown to AV/SV puncture. The extent of vasoconstriction front propagation was limited to the nearest valves. Histological examinations of collected CV samples revealed an altered spatial arrangement of myocytes in the tunica media at the level of leaflet attachment. Conclusions: Cephalic vein vasoconstriction is a rare phenomenon associated with accessing the venous system during first-time CIED implantation. The propagation of CV constriction was limited by the location of the nearest valves. (Folia Morphol 2018; 77, 3: 464–470)
6

Axillary vein spasm during cardiac implantable electronic device implantation

88%
Steckiewicz R., Gorko D., Swieton E. B., Szparecki G., Stolarz P.
Folia Morphologica
|
2016
|
tom 75
|
nr 4
Background: The technique of axillary vein (AV) or subclavian vein (SV) puncture has become an important alternative to cephalic vein (CV) cutdown as an approach allowing cardiac lead introduction into the venous system during cardiac implantable electronic device (CIED) implantation procedures. Irrespective of the technique used, the injury associated with lead insertion may induce a reflex venous spasm that can even cause total venous obstruction. In order to assess the incidence of AV spasm during AV puncture, we analysed a total of 735 (382 in females and 353 in males; mean age 75 ± 11 years) de novo CIED implantation procedures involving transvenous lead insertion conducted between January 2014 and December 2015. Materials and methods: In 337 patients the leads were introduced via AV puncture only, in 66 patients AV puncture was used in combination with CV cutdown, together yielding a total of 403 procedures (55% of all de novo CIED implantation procedures; mean patient age 72 ± 14 years), out of which we observed 12 cases (mean patient age 57 ± 25 years) of AV spasm (3%). Results: We evaluated only the procedures with unambiguous fluoroscopy images recorded during AV puncture: complete blockage of contrast medium flow through the AV, with preserved flow through the CV or collateral vessels, followed by eventually resumed flow of contrast via the AV. The contrast-enhanced movements of AV walls showed the spasm propagating both proximally and distally along the vessel, while the subsequent vessel wall relaxation occurred along the entire spasm-affected venous segment simultaneously. Conclusions: An AV spasm induced by AV puncture during CIED implantation is a rare phenomenon; however, if severe, it may significantly affect the course of the procedure. (Folia Morphol 2016; 75, 4: 543–549)
7

Imaging topography and morphometry of persistent left superior caval vein and its variations, detected on cardiac implantable electronic device implantation

88%
Steckiewicz R., Swieton E. B., Czerniawska J., Scislo P., Stolarz P.
Folia Morphologica
|
2017
|
tom 76
|
nr 1
Background: Persistent left superior caval vein (PLSCV) is a rare, anatomically diverse developmental anomaly of systemic veins. Clinically asymptomatic PLSCVs are detected incidentally during medical procedures that utilise systemic veins, such as cardiac implantable electronic device (CIED) placement, and whose successful completion depends on favourable morphometric parameters of these vessels. The aim of this paper was to present topography and morphometry of PLSCV variations encountered during CIED implantation procedures. Materials and methods: We analysed a group of 5,010 patients for detection of PLSCV during de-novo CIED implantation procedures with transvenous lead placement in the years 2003–2015. PLSCVs were detected intraprocedurally based on venographic images illustrating the venous anomaly and its morphometric parameters, and were subsequently confirmed via postoperative diagnostics. Results: PLSCVs were detected in 10 patients (mean age 66.0 ± 14.0 years; 5 females and 5 males), who constituted 0.2% of the analysed group. There were 6 cases of double superior vena cava (DSVC), 3 of which had a brachiocephalic vein (BCV) connection and did not have BCV bridging. Four patients with a PLSCV had right superior vena cava agenesis; this very rare variation is known as ‘single PLSCV’. All of the detected PLSCV variations drained into the right atrium via the coronary sinus. Conclusions: Our data from a period of 13 years illustrate how rare the PLSCV-type venous anomaly is. The three distinct anatomical PLSCV types showed inter-individual morphometric variations. Due to asymptomatic nature of this anomaly, all cases were detected incidentally, during CIED implantation procedures. (Folia Morphol 2017; 76, 1: 58–65)
8

Morphometric parameters of cardiac implantable electronic device (CIED) pocket walls observed on device replacement

76%
Steckiewicz R., Swieton E. B., Kolodzinska A., Bogdanska M., Fus L., Solarz P.
Folia Morphologica
|
2017
|
tom 76
|
nr 4
Background: The final stage of a conventional de-novo cardiac implantable electronic device (CIED) implantation procedure with transvenous lead insertion involves the formation of a pocket by tissue separation superficial to the pectoralis major muscle in the right or left infraclavicular region, where the device is subsequently placed. Over time, a scar “capsule” is formed around the CIED as a result of normal biological remodelling. Materials and methods: The purpose of this study was to analyse the structure and present the variations of CIED capsules observed during device replacement. The nature and extent of this local tissue remodelling, which had occurred from the time of device implantation to its replacement in 2016 (10 ± 3.1 years), was analysed in 100 patients (mean age 77.1 ± 14.5 years), including 45 women and 55 men. Results: The most prevalent types of “capsules” (70% of cases) were those with similar thickness of both walls or a slightly thicker posterior (< 1.0 mm) than anterior wall (< 0.5 mm). The second most common capsule type (23% of cases) was characterised by a significantly thicker posterior wall of scar tissue (> 1.0 mm). The third group of capsules was characterised by various degrees of wall calcification (7% of cases). Conclusions: The extent and nature of scar tissue structure in the CIED pocket walls seem to correlate with the relative position of cardiac lead loops with respect to the device itself; where the more extensive scarring is likely to result from pocket wall irritation in the capsule formation phase due to lead movements underneath the device. The group of cases with calcified capsules was characterised by “old” device pockets (> 13 years) and the oldest population (patients in their 80s and 90s). (Folia Morphol 2017; 76, 4: 675–681)
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