PMC9637934_01
(A) Venography via the left upper arm demonstrated total occlusion from the brachiocephalic vein (white arrow) to the superior vena cava (SVC) (arrowhead) with abundant collaterals. Left subclavian vein ( ). (B) TERUMO GLIDEWIRE  ( ) with support of a Mustang balloon (3.0 x 40 mm) failed to cross the junction of the brachiocephalic vein and SVC. (C) TERUMO GLIDEWIRE  ( ) with the support of a multipurpose catheter was advanced to the left internal jugular vein. The antegrade Hi-Torque Connect  guidewire was successfully advanced to the inferior vena cava. (D) A Mustang balloon (12.0 x 80 mm) was used to dilate the SVC and brachiocephalic vein with 6 atm.
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F1
The preprocedural venogram showed partial stenosis in the proximal left SCV, severe stenosis in brachiocephalic vein and Standford type III SVC occlusion (Figure 1A). With the support of a Mustang balloon (3.0 x 40 mm), we passed a 0.035-inch TERUMO GLIDEWIRE  through the stenotic lesion of the left SCV and the brachiocephalic vein but could not cross the SVC total occlusion (Figure 1B). We escalated the wire to a 0.018-inch Hi-Torque Connect  wire (Figure 1C) but we still failed to pass it through the lesion. Under the guidance of the retrograde guidewire, the antegrade Hi-Torque Connect  wire crossed the SVC total occlusion and was advanced to the inferior vena cava (Figure 1C). A Mustang balloon (3.0 x 40 mm) and a Mustang balloon (12.0 x 80 mm) were used to dilate the brachiocephalic vein and the SVC sequentially (Figure 1D).
(A) The angiogram showed a patent brachiocephalic vein and superior vena cava after balloon venoplasty. (B) Implantation of right atrial, right ventricular and left ventricular leads.
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F2
The post-dilation angiogram revealed patent flow (Figure 2A). An active fixation lead in the right ventricle (Medtronic 5076-58 cm), an active fixation lead in the right atrium (Medtronic 5076-52 cm) and a generator (Medtronic Percepta ) with DDDR mode were implanted smoothly (Figure 2B).