Subclavian chronic total occlusion angioplasty facilitates cardiac implantable electronic device upgrades: A single-center case series

Subclavian venous occlusion is a frequent complication of transvenous cardiac implantable electronic device (CIED) implantation, with reported incidences exceeding 30%. Although often asymptomatic, chronic total occlusion (CTO) creates a major technical barrier during device revision, particularly for cardiac resynchronization therapy (CRT) upgrades. Conventional strategies such as lead extraction or contralateral tunneling may increase procedural risk or compromise future vascular access. Subclavian CTO venoplasty is a minimally invasive alternative to re-establish ipsilateral access. We describe a single-center series of six patients (ages 62–78 years) who underwent percutaneous subclavian, axillary, or brachiocephalic venoplasty to facilitate CIED upgrade or lead revision. Our approach favored ipsilateral upper-extremity access (typically basilic vein) with a 0.018-inch platform using polymer-jacketed guidewires and microcatheters for CTO crossing. Serial balloon angioplasty (4.0–10.0 mm; 40–80 mm length range) was performed using stepwise inflation (nominal pressure with escalation as needed up to rated burst pressure per device specifications) to restore venous patency. Technical success was achieved in all six cases (100%), enabling four CRT implantations, one left bundle branch area pacing (LBBAP) implant, and one dual-chamber lead revision. No major intraprocedural complications occurred; one patient developed a self-resolving chest wall hematoma. Procedure time ranged from 116 to 240 min. Among CRT recipients, QRS duration narrowed (mean reduction 45 ± 18 ms). Follow-up (2–12 months) demonstrated stable lead parameters and no clinical evidence of recurrent occlusion. In this small series, subclavian/central venous CTO venoplasty using a brachial-first, 0.018-inch CTO-oriented strategy was feasible and enabled successful ipsilateral CIED revision while preserving vascular access. Larger studies are needed to better define the success rate and safety relative to the extraction or subclavian/device pocket access only approach.