Symptomatic subclavian vein stenosis and occlusion in hemodialysis patients with transvenous pacemakers

The objective of this study was to determine the incidence and timing of complications associated with ipsilateral transvenous pacemakers and hemodialysis access, including subclavian vein stenosis and occlusion, and assess their impact on dialysis access patency. All patients who had pacemakers placed at St. Francis Medical Center were reviewed during the 10-year period from 1988 to 1998. Patients requiring chronic hemodialysis were identified and their demographic data, the presence of arm swelling, and fistula patency were noted. Development of subclavian vein stenosis and occlusion was documented by venography in symptomatic patients. The ultimate outcome of dialysis access was recorded. During the 10-year period 495 patients had transvenous pacemakers placed. Twenty patients were identified with renal failure requiring hemodialysis and 14 had hemodialysis access in the extremity ipsilateral to the pacemaker. Ten (10/14, 71%) patients developed symptoms of subclavian stenosis, including venous hypertension, high recirculation rate, arm swelling, pain, and neurologic symptoms. Eighty percent (8/10) of symptomatic patients had subclavian vein occlusion. All 10 symptomatic patients required ligation of the hemodialysis access to control symptoms. The four asymptomatic patients expired within 6 months of placement of the pacemaker or hemodialysis access from unrelated causes. There is a high incidence of complications in patients who have ipsilateral pacemakers and hemodialysis access. The presence of pacemaker electrodes in the subclavian vein and the flow associated with hemodialysis may accelerate the occurrence of subclavian venous stenosis and occlusion. Patients who did not develop symptoms may have expired before venous outflow obstruction could develop. Vascular surgeons and cardiac surgeons/cardiologists need to coordinate their procedures to avoid ipsilateral transvenous pacemakers and hemodialysis access.