A RARE COMPLICATION OF LEAD EXTRACTION: THE A–V FISTULA

Abstract We describe the case of a 59 years–old male patient with dilated idiopathic cardiomiopathy (left ventricle ejection fraction 20%), type 2 diabetes mellitus, arterial hypertension, atrial fibrillation, dyslipidemia, chronic kidney disease. The patient underwent the implantation of a bicameral implantable cardioverter defibrillator (ICD) for primary prevention in 2002, with subsequent upgrading to a cardiac resynchronization therapy defibrillator (CRT–D) in January 2021. The patient came to our Hospital for pocket erosion in October 2021, after an unsuccessful course of antibiotic therapy with clarithromycin. During hospitalization, we found positive blood cultures for Staphylococcus aureus. The ECOTEE showed a 1 cm filamentous mobile mass adhering to the right ventricular lead, compatible with vegetation. Before lead extraction, a venous angiography was performed, showing patency of the anonymous–subclavian–right caval venous axis and total occlusion of the left axis with collateral circulation. At October 20th 2021 transvenous lead extraction (TLE) was performed. The coronary sinus lead was manually removed. During the extraction of the passive fixation dual–coil right ventricular lead (using powered mechanical sheaths and laser sheaths), profuse bleeding started following sheath removal. The angiography showed an arteriovenous fistula between the subclavian vein and the left internal mammary artery. The patient remained hemodynamically stable, with no signs of hemothorax. The lead extraction procedure was halted. The fistula closed spontaneously and embolization was not required. Two computed tomography scans (CT) were performed, revealing spontaneous closure of the fistula without further complication. The patient was continuously monitored at in our cardiac intensive care unit (CICU) without any further complications. On November 23rd a complete lead extraction was performed without complications. On December 18th the patient was implanted with a new CRT–D device from the right side. No complication occurred. The patient was discharged 48h later in good general conditions. The junction between the left brachiocephalic vein and the superior vena cava is a high–risk region during lead extraction. Venous laceration with hemodynamic collapse is the most severe complication arising in this region, but arteriovenous fistula formation after excimer laser extraction also has been reported as a rare complication.