Introduction
Upper extremity venous occlusion is a common complication encountered after transvenous lead placement that presents either acutely or chronically. Thrombus formation presents acutely with a painful, swollen upper extremity. Treatment can include catheter directed thrombolytics or anticoagulants/antiplatelet medications in an attempt to reduce thrombus burden and allow time for collateral formation (1)(2). Patients with acute symptoms that fail to resolve have undergone balloon dilation or subsequent stenting even though both techniques are associated with high rate of restenosis. Chronic lead related irritation of the venous endothelium results in neointimal hyperplasia with fibrosis. In many patients the lead related fibrosis eventually results in venous obstruction. Patients typically remain asymptomatic, due to formation of collateral circulation as fibrosis ensues (3) and the obstruction is typically discovered at the time of lead addition or replacement. Those who present with chronic symptoms presumably related to limited collaterals are sometimes managed with balloon dilation although symptoms quickly recur. The addition of stenting to balloon dilation has similar results in jailing and potential damage to the leads. The management of chronic lead related symptomatic venous obstruction is not well established. Herein we discuss the addition a paclitaxel-coated balloon (PCB) to high pressure balloon dilation as a potential way to improve the results in chronic symptomatic lead related venous obstruction