Balloon Dilation of an Inferior Vena Cava Filter to Implant a Leadless Pacemaker James Gabriels, MD, a Roger Fan, MD, b Stuart Beldner, MD, a Ram Jadonath, MD, a Mitchell Weinberg, MD, c Apoor Patel, MD a A 65-year-old woman required a permanent pacemaker due to tachycardia-bradycardia syndrome. Vascular access was complicated by a left arm arteriovenous graft and a prior right up- per extremity fistula. Imaging revealed occlusion of a previous right subclavian vein stent, right brachioce- phalic vein, and right internal jugular vein. The patient was felt to be at high operative risk for an epicardial lead due to prior coronary artery bypass graft surgery and recent percutaneous coronary inter- vention necessitating dual antiplatelet therapy. A decision was made to implant a Micra Pacemaker (Medtronic Inc., Minneapolis, Minnesota). The 27-F Micra delivery system could not be advanced past the patient’s nonretrievable inferior vena cava (IVC) filter, which was implanted 20 years prior. The filter was crossed in a subsequent proced- ure initially with an angled support catheter. A 10.0- Â 40-mm Mustang balloon (Boston Scientific, Marlborough, Massachusetts) on a 75-cm shaft was then inflated within the filter. The deflating balloon was used as a rail for the advancing sheath (Figure 1, Online Video 1), resulting in successful implantation of the Micra pacemaker in the right ventricular apex without complications. Prior reports have demonstrated that a femoral approach can be used to pass multiple 6- to 7-F catheters and 8-F sheaths across IVC filters (1). Afzal et al. (2) reported a case where a Micra permanent pacemaker was successfully implanted via an IVC filter; however, there are a variety of technical and clinical factors that affect the ability to cross a filter or the decision to instrument them at all. Filter design, duration of the implantation, interaction of the filter with the caval wall, extent of in-filter thrombus, and the patient’s ability to tolerate anticoagulation in the event the filter is rendered less effective post-dilation all may affect the crossing process. To our knowledge, this is the first report of leadless pacemaker place- ment following balloon-facilitated IVC filter crossing. ADDRESS FOR CORRESPONDENCE: Dr. James Gabriels, Department of Cardiology, North Shore University Hospital, Northwell Health, 300 Community Drive, 4DSU GME Suite, Manhasset, New York 11030. E-mail: jamesgabriels@gmail.com. From the a Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Man- hasset, New York; b Division of Electrophysiology, Department of Cardiology, Stony Brook University Hospital, Stony Brook, New York; and the c Division of Vascular Medicine and Vascular Intervention, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page. Manuscript received June 5, 2017; accepted June 15, 2017. JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 3, NO. 13, 2017 ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER ISSN 2405-500X/$36.00 http://dx.doi.org/10.1016/j.jacep.2017.06.014