Central Vein Stenosis in ESRD with Cardiac Device Leads

Introduction: Central vain stenosis CVS is common problem in haemodialysis patients.main cause of CVS is presence of haemodialysis catheter and presence of cardiac device leads .Treatment of pacemaker induced central vain stenosis with balloon venoplasty may associated with serious complications of the device leads. Case Description: We reported a 65 years old female patient know to have DM,HTN ,IHD,Low EF , history of cardiac arrhythmias. She has cardiac device with 4 leads crossing the left subclavian vain to heart chamber. She had history of CVS with symptomatic superior vena cave syndrome SVCS which needs venoplasty. the concern in regards to the size of balloon to be used for venoplasty without causing any complications to the cardiac leads hence we avoid large ballon and we used lower balloon size with insufficient result for venoplasty dilatation . Discussion: Central vain stenosis (CVS ) is common in HD patients .the main causes of CVS is presence of haemodialysis catheter and presence of cardiac device like Pace makers/AICD leads ,The pathophysiology of CVS due to irritatation of the endothelium which activate a cascade of inflammatory process leads to neointimal hyperplasia , wall thinking, mural thrombus , fibrosis and endoluminal obstruction. HD patient with cardiac device at high risk of CVS which can cause SVC syndrome. Therefore early detection and intervention may prevent long term complications.There is different approach in management of cardiac pacemaker lead-induced central balloon venoplasty best approach with acceptable risk .However in patient with cardiac device and there leads cross the central vain stenosis the balloon dilatation may lead to serious complications related to leads including irritation of the leads or more serious complication rupture of the leads particularly if the lesion too stenotic and rigid higher balloon size needed .in certain high risk patients the endovascular intervention may be unsuccessful and risky where surgical intervention may better option. CONCLUSIONS Cardiac device with leads widely used in haemodialysis patients. increaseing the risk of CVS and compromise the AVF creation.endovascular balloon angioplasty acceptable approach for treatment but may associated with major complications and risk affecting the leads . Therefore multidisciplinary team approach from cardiology EP specialist and interventional nephrologists needs to be established.