A comparison of lead placement through the subclavian vein technique with fluoroscopy-guided axillary vein technique for permanent pacemaker insertion

Background

The intrathoracic subclavian venous technique for pacemaker implantation may be associated with serious complications. We describe an alternative technique for obtaining venous access for pacemaker implantation through axillary vein under fluoroscopic guidance and compare it with the conventional, subclavian approach.

Methods

We conducted a single-centre, prospective, nonrandomized study. All adult patients with indication for permanent pacing who consented were recruited during a 3-year period. To access the axillary vein, we used the alternative technique with a new fluoroscopic landmark. The subclavian access was obtained as per the usual approach.

Results

We studied 478 lead placements during 3 years; 315 lead placements through axillary venous technique (group 1) were compared with 163 lead placements through subclavian venous technique (group 2). Both routes had a high and comparable success rate, 98.09% in group 1 and 96.93% in group 2. The axillary approach was successful at the first attempt in 194 punctures (61.6%), as vs 60 in group 2 (36.8%) P < 0.0001. The average number of attempts in group 1 was 2.06 per patient and 2.56 in group 2 (P < 0.001). There were 3 (2.94%) pneumothoraxes in group 2 and none in group 1. During a mean follow-up period of 3.2 months in group1 and 3.7 months in group 2, 1 patient in group 2 had a lead fracture.

Conclusions

The fluoroscopically guided axillary venous approach for implanting permanent pacemakers is equivalent to the traditional anatomic landmark–guided intrathoracic subclavian approach and has fewer complications and shorter procedural time to access the vein.     

Prospective study to develop surface landmarks for blind axillary vein puncture for permanent pacemaker and defibrillator lead implantation and compare it to available contrast venography guided technique

Objective

To develop surface landmarks for blind axillary vein puncture for pacemaker lead implantation.

Methods and results

Patients for routine coronary angiography were counseled for participating in our study. 20 patients who gave consent were taken up for axillary venogram after proper positioning at the time of coronary angiogram. The venograms of these 20 patients, were reviewed and the landmarks were used to develop a blind axillary puncture technique. Success rate of 100% was achieved with surface landmark guided axillary vein puncture. The implantation time while using surface landmark guided axillary puncture was not significantly longer than when venography based approach was used. Another interesting observation made from the study was that increasing BMI had a positive correlation with the time taken for venous access, the fluoroscopic time and the volume of contrast used, all the associations being statistically significant. Thus, the surface landmark guided technique is more safe and expeditious in non obese patients and probably in pediatric patients as well. Moreover, the new surface landmark guided approach is a significant safety step in terms of reducing the unwanted and avoidable radiation exposure to the hands.

Conclusion

The results of this study demonstrate that placement of endocardial permanent pacemaker and ICD leads via the developed surface landmarks is effective and safe and is devoid of the harmful effects of radiation and contrast exposure.     

Permanent Pacing from a Left Ventricular Vein in a Patient with Persistent Left Superior Vena Cava and Absent Right Superior Vena Cava: Use of an Over-the-Wire System

In patients with a persistent left superior vena cava, placement of a permanent transvenous pacing lead for ventricular pacing via the left subclavian vein can be technically challenging. Permanent pacing was achieved in a patient with a persistent left superior vena cava and absent right superior vena cava using a left ventricular vein. Use of an over-the-wire lead system greatly facilitated this procedure.     

Venous Thrombosis and Stenosis After Implantation of Pacemakers and Defibrillators

Venous complications of pacemaker/ implantable cardioverter defibrillator (ICD) system implantation rarely cause immediate clinical problems. The challenge starts when patients come for system revision or upgrade. Numerous reports of venous complications such as stenosis, occlusions, and superior vena cava syndrome have been published. We reviewed current knowledge of these complications, management, and their impact on upgrade/revision procedures. One study has suggested that intravenous lead infection promotes local vein stenosis. Another found that the presence of a temporary wire before implantation is associated with an increased risk of stenosis. Although data for ICD leads is based only on three studies—it suggests that the rate of venous complications is very similar to that of pacing systems, and probably data from pacing leads can be extrapolated to ICD leads. Despite 40 years of experience with transcutaneous implanted intravenous pacing systems and dozens of studies, we were unable to identify clear risk factors (confirmed by independent studies) that lead to venous stenosis. Neither the hardware (lead size, number and material) nor the access site choice (cephalic cut down, subclavian or axillary puncture) appears to affect rate of venous complications. A few factors were proposed as predictors of severe venous stenosis/occlusion: presence of multiple pacemaker leads (compared to a single lead), use of hormone therapy, personal history of venous thrombosis, the presence of temporary wire before implantation, previous presence of a pacemaker (ICD as an upgrade) and the use of dual-coil leads. Anticoagulant therapy (for other reasons than pacemaker lead) seemed to have protective antithrombotic effect.     

Venogram-guided extrathoracic subclavian vein puncture

BACKGROUND: Subclavian vein puncture is commonly performed to insert the pacing lead for permanent pacemaker implantation. Our aim was to study the safety and feasibility of venogram-guided extrathoracic subclavian vein puncture for permanent pacemaker lead insertion. METHODS AND RESULTS: Sixty patients (32 males, and 28 females) underwent permanent pacemaker lead insertion by extrathoracic subclavian vein puncture at our institute between March 2002 and December 2002. Fifteen patients underwent dual-chamber and 45 single-chamber pacemaker implantation. All the patients underwent extrathoracic subclavian vein puncture guided by venogram, except 1 who underwent dual-chamber pacemaker implantation in whom the ventricular lead insertion was via the cephalic vein on an elective basis. The procedure was successful in all the patients. Inadvertent subclavian artery puncture occurred in 2 patients without any complication. There was no incidence of pneumothorax, hemothorax or pacemaker site infection. CONCLUSIONS: Venogram-guided extrathoracic subclavian vein puncture is safe and successful. It may be adopted as one of the preferred approaches for permanent pacemaker lead insertion.     

Permanent pacing in patients with congenital atrio-ventricular block--experience of 33 cases.

OBJECTIVES: The authors review permanent pacing in patients with congenital atrioventricular block (CAVB) and present their experience in permanent pacing in this pathology. STUDY POPULATION AND METHODS: In a population of 4,355 patients submitted to implantation of permanent pacing between January 1980 and January 1998, 33 (0.75%) had CAVB. The mean age of the patient population with CAVB was 16.7 years (aged from eleven days to 35 years); 33% were below 10 years of age; 16 patients were male. The majority of the patients had symptoms of brain hypoperfusion; two patients had concomitant malignant ventricular tachyarrythmias (one of these with Torsade de Pointes due to congenital long QT syndrome). Transvenous (endocardial) pacing was used in 32 patients (two with previous epicardial pacing and exit block) and epicardial pacing in one. The mode of stimulation used was VVI in three patients, DDD in eight patients, VVIR in 14 patients, DDDR in four patients and VDD in four. Smaller pulse generators were used in children of lower weight. In recent years single lead VDD systems have been preferred whenever technically possible. Vascular access was the left cephalic vein in 17 patients; the left subclavian vein in 14 patients and the right jugular vein in one patient. During a mean follow-up of 6.9 years, two patients with ventricular stimulation systems developed "Pacemaker Syndrome" and required a change of mode of stimulation. Lead fracture and posterior cutaneous necroses were observed in two other patients, who were accordingly submitted to surgical revision. It was deemed necessary, one year later, to increase the lead loop in a child with a permanent pacemaker implanted at eleven days of age. No other complications occurred with the other patients; replacement of the pulse generators was performed in an elective manner. CONCLUSIONS: CAVB is a rare indication for the implantation of a permanent pacemaker. In children, in the majority of cases, endocardial stimulation is possible in spite of the obvious technical difficulties due to low weight. Sequential, more physiological, stimulation systems should be preferred. However, VVIR stimulation systems of smaller dimensions can be the first choice of mode of stimulation in smaller children, mainly due to anatomical and technical limitations.     

Erfahrungen mit einer neuen transvenösen Sonde zur linksventrikulären Stimulation

BACKGROUND: Left ventricular and biventricular pacing has recently been introduced as a new therapy for chronic heart failure in selected patients. We report our initial experience with a new electrode for transvenous left epicardial pacing via tributaries of the coronary sinus. PATIENTS AND METHOD: Inclusion criteria were: chronic heart failure NYHA > or = II, QRS-duration > 120 ms, left ventricular ejection fraction < 35%. Dual chamber pacemakers (CPI Contak TR) or defibrillators (CPI Contak CD) designed for atrial triggered biventricular stimulation were implanted in conjunction with the CPI Easytrak-lead for left ventricular pacing in a coronary vein. Lead placement was achieved via a subclavian vein access and a preformed guiding catheter for coronary sinus insertion. RESULTS: In 13 of 16 patients (81%) the left ventricular lead was implanted successfully in a mid to distal posterior or anterolateral vein. Lead insertion could not be achieved in 2 patients with significant cardiomegaly and right atrial enlargement (12.5%), while 1 patient with a history of myocardial infarction and small anterior ventricular aneurysm had inacceptable high left ventricular pacing thresholds intraoperatively. The implantation was well tolerated by all patients without complications. There was no case of lead dysfunction (mean follow-up time: 142 +/- 126 days). Intraoperative electrode measurements and chronic parameters (> or = 3 months, n = 8) are given in Table 1. CONCLUSION: In the past left ventricular pacing has mainly been achieved by epicardially placed electrodes after thoracotomy with conventional electrodes. This new approach for chronic left ventricular pacing uses the familiar transvenous over-the-wire technique in combination with a newly developed guiding catheter and electrode for pacing in left epicardial veins. Lead placement was shown to be safe and success rate was higher than in previous reports with standard electrodes. We conclude that left epicardial lead placement with the over-the-wire technique and a preformed guiding catheter for coronary sinus access presents as a safe and maybe more efficient method for left ventricular pacing.     

置入双腔起搏心脏复律除颤器及经腋静脉送入心内电极的初步临床体会

目的初步评价新型双脏起搏心脏复律除颤器抗室性心动过速／心室颤动（室速／室颤）及心动过缓起搏的临床效果,了解经腋静脉送人心房及心室电极的安全性及有效性。方法７例室速及（或）室颤同时伴有心动过缓患者接受了双腔起搏心脏复律除颤器治疗,其中冠心病５例、扩张性心肌病２例。心房及心室电极均在Ｘ线透视、静脉注人造影剂指导下,直接穿刺腋静脉,从该静脉送人。结果脉冲发生器埋在左上胸皮下５例,埋在胸大肌与胸小肌之间２例。仪器对所有室速／室颤均能及时识别并成功治疗,同时提供有效的房室顺序起搏功能。所有心内电极均成功地经腋静脉送人,无并发症。结论双腔起搏心脏复律除颤器不但能有效地治疗严重室性心律失常,而且提供可靠的房室顺序性起搏功能。经腋静脉送入电极安全、可靠。     

80岁以上老年人心脏起搏器植入术及减少并发症的对策

目的 探讨80岁以上老年人起搏器植入手术方式的选择,旨在减少相关并发症及提高生活质量.方法 80岁以上老年人127例植入起搏器.其中双腔起搏（包括双室三腔起搏）95例（74.8%）;单腔心室起搏32例（25.2%）.所有患者首选经头静脉放置起搏电极导线,并对寻找头静脉及电极导线植入方式做了较大的改进.电极导线的头端应固定在心腔内,切口内起搏器囊袋处的固定也十分重要.在电极导线送入心内前制作起搏器囊袋,并放置纱布压迫止血,对少数渗血较多的患者,局部适当加凝血酶或用电凝刀止血.鼓励患者术后早期下床（手术当日或次日）.结果 经头静脉送入起搏导线的成功率,在单腔起搏器为92.0%,双腔起搏器81.5%.术中及术后早期发生并发症5例（3.9%）,分别是：囊袋血肿3例（2.4%）,电极导线与起搏器连接处松动1例（0.8%）,心肌穿孔1例（0.8%）.无血气胸、电极导线脱位及起搏器囊袋感染发生.结论 经头静脉送入起搏电极导线可避免锁骨下穿刺所导致的并发症,在老年人中尤其重要;电极导线脱位主要与手术操作有关,而与早期下床活动无关;应采用适当方法达到囊袋内彻底止血,减少术后囊袋血肿及感染.     

Use of an Active-Fixation Coronary Sinus Lead to Implant a Biventricular Pacemaker via the Femoral Vein

Cardiac resynchronization therapy, which involves the placement of a pacing lead in the right atrium and in each ventricle, is effective in treating heart failure that is caused by left bundle branch block and cardiomyopathy. The left ventricular lead is usually placed into a lateral branch of the coronary sinus via the subclavian route. When the subclavian route is unavailable, insertion of a standard, passive-fixation coronary sinus lead via the femoral approach is feasible; however, the likelihood of subsequent dislodgment is high. Herein, we describe the placement of a novel, self-retaining, active-fixation coronary sinus lead—the Attain StarFix® Model 4195 OTW Lead—in an elderly heart-failure patient, via the femoral approach. We believe that this is the 1st report of this procedure.Key words: Aged, 80 and over; cardiac pacing, artificial/methods; cardiomyopathy; catheterization, central venous/contraindications; electrodes, implanted; femoral vein; heart failure/complications/therapy; quality of life; treatment outcomeIn cardiac resynchronization therapy, coronary sinus (CS) lead placement is required for the implantation of an endocardial biventricular pacemaker. The insertion of passive-fixation CS leads via the femoral vein¹ is typically avoided because of the high likelihood of lead dislodgment, although this route remains useful when subclavian venous access is unattainable. Here, we describe our use of the femoral approach in combination with an active-fixation CS lead to place a biventricular lead system and pacemaker in an elderly patient.     

Clinical Predictors of Successful Cephalic Vein Access for Implantation of Endocardial Leads

Background: The purpose of this study was to determine whether there are any patient characteristics that predict successful use of the cephalic vein for endocardial lead implantation. Methods: One-hundred fifty consecutive patients who underwent implantation of one or more endocardial pacemaker (N = 63) or defibrillator (N = 87) leads using a cephalic vein approach were included in this prospective study. The mean age of the patients was 63 ± 14 years, and 115 (77%) were men. Ninty-one patients (61%) had coronary artery disease, 77 patients (51%) had hypertension, and 42 patients (28%) had diabetes. The mean ejection fraction was 0.34 ± 0.17. Results: At least one lead was successfully implanted using a cephalic vein approach in 96 patients (64%). The most common reason for failure of the cephalic vein approach was a small cephalic vein, found in 25 patients (17%). Independent predictors of successful cephalic vein use were diabetes (p < 0.001), ejection fraction 0.40 (p < 0.05), and male gender (p < 0.05). At least one endocardial lead was implanted in 19 of the 24 (79%) men who had an ejection fraction 0.40 and diabetes, compared to 4 of the 11 (36%) women who had an ejection fraction >0.40 and did not have diabetes. The only independent predictor of successful cephalic vein implantation among nondiabetics was an ejection fraction 0.40 (p < 0.01). Body size was not an independent predictor of successful cephalic vein use. Conclusion: Baseline patient characteristics influence the likelihood of successful endocardial lead implantation using a cephalic vein approach. Diabetes, ventricular dysfunction, male gender and are associated with an increased likelihood of a successful implant using the cephalic vein. Smaller leads and and better techniques are needed to improve the success rate of cephalic vein implantion in all patients.     

Prevalence of central venous occlusion in patients with chronic defibrillator leads

BACKGROUND: Many patients with previously implanted ventricular defibrillators are candidates for an upgrade to a device capable of atrial-ventricular sequential or multisite pacing. The prevalence of venous occlusion after placement of transvenous defibrillator leads is unknown. The purpose of this study was to determine the prevalence of central venous occlusion in asymptomatic patients with chronic transvenous defibrillator leads. METHODS: Thirty consecutive patients with a transvenous defibrillator lead underwent bilateral contrast venography of the cephalic, axillary, subclavian, and brachiocephalic veins as well as the superior vena cava before an elective defibrillator battery replacement. The mean time between transvenous defibrillator lead implantation and venography was 45 +/- 21 months. Sixteen patients had more than 1 lead in the same subclavian vein. No patient had clinical signs of venous occlusion. RESULTS: One (3%) patient had a complete occlusion of the subclavian vein, 1 (3%) patient had a 90% subclavian vein stenosis, 2 (7%) patients had a 75% to 89% subclavian stenosis, 11 (37%) patients had a 50% to 74% subclavian stenosis, and 15 (50%) patients had no subclavian stenosis. CONCLUSIONS: The low prevalence of subclavian vein occlusion or severe stenosis among defibrillator recipients found in this study suggests that the placement of additional transvenous leads in a patient who already has a ventricular defibrillator is feasible in a high percentage of patients (93%).     

Acute and early complications of permanent pacing: A prospective audit of 926 consecutive patients from a UK center

To evaluate the incidence of intraoperative and early postoperative complications (up to 2 months after implant) of endocardial permanent pacemaker insertion in all patients undergoing their first implant at our Center, we prospectively evaluated all pacemaker implantation procedures performed from April 1992 to September 1993. A standard audit form was completed at implant, recording patient demographic data, medical history, details of pacemaker hardware used, and any acute complications. Follow-up information was also collected prospectively onto standard forms at the pacemaker outpatient clinic. The study was performed in a United Kingdom tertiary referral Cardiothoracic Center. Nine hundred and fifty consecutive patients underwent implantation of their first endocardial permanent pacemaker from April 1992 to September 1993. Implant and follow-up data to 2 months were available on 926 (97.5%) of these patients at analysis, 51.4% were male (median age 77 years; range 16–99). Dual chamber units were implanted in 53% of patients, single chamber atrial in 6%, and ventricular in 41%. At implant, 23% of patients had a temporary pacing leadin situ. Most (93%) implants were performed via the subclavian vein. Acute complications were rare: 9 patients developed pneumothorax requiring medical treatment and 10 patients developed an insignificant pneumothorax. Arterial puncture without sequelae was documented in 2.7% of attempts at subclavian vein cannulation. Complications requiring re-operation occurred in 3.5% of patients overall; lead displacement [n=14 patients (1.5%)] was the most common reason for re-operation. Atrial lead displacement [n=10 patients (1.85% of atrial leads)] was significantly more common than ventricular lead displacement [n=4 patients (0.46% of ventricular leads),p=0.02]. Pacemaker pocket infection led to reoperation in 9 patients (0.97%) and was significantly more common in patients with a temporary pacing lead at implant (2.35%) compared with those without (0.56%,p<0.05). Five patients (0.5%) required re-operation for generator erosion and a further 5 (0.5%) for drainage of hematoma or a serous fluid collection. Complications that did not require re-operation occurred in 2.4% of patients overall: atrial (n =8) and ventricular (n=1) undersensing was successfully treated by reprogramming of sensitivity in all cases. Superficial wound infection was treated successfully with antibiotics in eight patients. Six patients with DDD generators developed atrial fibrillation: one was cardioverted, two required reprogramming to VVI mode, and three reverted spontaneously to sinus rhythm. In summary, permanent pacing in a large tertiary referral center with experienced operators carries a low risk. Infection rates are low (<1%). Lead displacement and undersensing are more likely to occur with atrial than with ventricular leads. The overall complication rate for dual chamber pacing is no higher than for single chamber pacing.Presented at the 36th Annual World Congress, International College of Angiology, New York, New York, July 1994     

经头静脉放置起搏电极导线手术方式的改进及临床意义

目的探索经胸横切口暴露头静脉及使用导引钢丝、静脉鞘管引导放置起搏电极导线的成功率及临床意义.方法 220例具备起搏治疗指征的病人,在右上外侧胸部做横切口分离头静脉,当经该静脉直接送入起搏电极导线有困难时,在导引钢丝及静脉鞘管的引导下送入电极导线.如果经以上方法均不能顺利放置电极导线,则经切口内穿刺锁骨下静脉送入电极导线.起搏器埋藏在头静脉切口内侧的皮下囊袋内.结果横切口同样能良好地暴露头静脉.此外,当需要经锁骨下静脉穿刺时,直接经该切口内穿刺不但方便,而且减少创伤.直接经头静脉放置单腔及双腔起搏器电极导线的成功率分别为71%及58%,加用导引钢丝及静脉鞘管后成功率分别提高到94%及88%(P值均<0.01).结论经胸做横切口分离头静脉结合使用导引钢丝及静脉鞘管技术可显著性提高经头静脉放置起搏电极的成功率,减少锁骨下静脉穿刺及相应的并发症,并方便起搏器的放置.     

Feasibility and Accuracy of Pre-procedure Imaging of the Proximal Cephalic Vein by Duplex Ultrasonography in Pacemaker and Defibrillator Implantation

BACKGROUND: Failure of the cephalic venous approach in pacemaker and defibrillator implantation is always due to the small size and difficulty in isolation of the cephalic vein. We propose that pre-procedure imaging of the proximal cephalic vein is valuable to achieve successful access of cephalic vein. However, the feasibility and accuracy of duplex ultrasonographic imaging of the proximal cephalic vein are unknown. METHODS: The study enrolled 30 consecutive patients who underwent new implantation of permanent pacemakers or defibrillators at our institute. An ultrasound probe scanned along the plane 2 cm beneath the inferior margin of the clavicle to locate the cephalic vein before device implantation. If the vein was well visualized, the venous diameter and the vertical depth were measured. The corresponding surface location of the vein on the chest wall was also identified and recorded by duplex ultrasonography. The echo-derived vertical depths and vascular findings were compared with those measured during surgery. RESULTS: All proximal cephalic veins were well visualized in the infraclavicular region by duplex ultrasonography. They were compressible, patent in color Doppler ultrasound imaging, and displayed phasic change of Doppler signal during respiration, indicating patency in all study veins. The average diameter of the target cephalic vein was 7.7 +/- 1.6 mm (range, 5.0-11.1 mm). The echo-derived vertical depth of the proximal cephalic veins was highly correlated with the depth measured during surgery (28.4 +/- 5.5 vs. 28.4 +/- 5.6 mm, r = 0.93, P < 0.0001). All target cephalic veins were isolated after exploration via the estimated surface location of the chest wall by pre-procedure duplex ultrasonography. Seven (23%) of the studied patients did not have their cephalic vein cannulated successfully. CONCLUSION: The target proximal cephalic vein in pacemaker and defibrillator implantation can be precisely imaged and localized by duplex ultrasonography. Although further studies are needed, our findings pave a way to further study and clarify the implantation problems of cephalic vein approach.     

Inadvertent permanent ventricular pacing from the coronary vein: an electrocardiographic, roentgenographic, and echocardiographic assessment

The incidence of inadvertent permanent ventricular pacing from the coronary vein is not known. In a retrospective analysis of 69 patients in whom transvenous pacemakers were implanted between 1979 and 1986, 12 patients were discovered to have right bundle-branch block pattern to the paced complexes on electrocardiogram. In this group, three patients were considered to have inadvertent placement of pacing lead in the coronary vein by two-dimensional echocardiographic criteria. No complications were noted in follow-up of 2-79 months. Monitoring of surface electrocardiogram, frontal and lateral fluoroscopy, and pacing threshold and sensing parameters (during implantation of pacemaker) were found to offer no absolute protection against malplacement of the lead. Placement of the lead into the lung field via the main pulmonary artery and then withdrawing with eventual positioning into the right ventricular apex will avoid malposition into the coronary vein. Two-dimensional echocardiography is useful for the diagnosis of pacing lead malplacement and should be performed in any patient with right bundle-branch block pattern in the surface electrocardiogram following pacemaker implantation.     

经腋静脉和锁骨下静脉途径植入或拔除心内膜电极的对比研究

目的 探讨经皮腋静脉穿刺植入与拔除心内膜电极导线的可行性与安全性.方法 538例具有起搏器或植入式心律转复除颤器（implantable cardioverter defibrillator,ICD）植入指征的患者分为实验组与对照组,分别经腋静脉途径和经锁骨下静脉途径植入心内膜电极导线.对比分析两种途径植入心内膜电极导线的穿刺成功率和并发症.对同期入院因起搏器囊袋感染拔除心内膜电极导线的47例患者和81例起搏器升级患者的手术情况进行回顾分析,对比不同植入途径心内膜电极导线拔除成功率和增加心内膜电极导线的成功率.结果 实验组与对照组穿刺成功率及并发症发生率比较,差异无统计学意义[98.5％（268/272） vs.98.9％（263/266）,P＞0.05; 13.2％（36/272） vs.13.9％ （37/266）,P＞0.05].其中,对照组发生锁骨下静脉挤压综合征1例,气胸5例,实验组无一例发生气胸和锁骨下静脉挤压综合征.经腋静脉途径植入心内膜电极导线的拔除成功率及新增电极导线的植入成功率均高于经锁骨下静脉途径,差异有统计学意义[94.4％（17/18）vs.86.2％（25/29）,P＜0.05;97.2％（35/36）vs.88.9％（40/45）,P＜0.05].结论 经腋静脉途径植入心内膜电极导线安全可行,并为可能的电极导线拔除和起搏器升级增加心内膜电极导线预留更大的解剖空间,值得在临床推广应用.     

Coronary vein balloon angioplasty for left ventricular pacemaker lead implantation

OBJECTIVES: Retrospective analysis of five cases of coronary vein balloon angioplasty performed to allow insertion of left ventricular pacing leads. BACKGROUND: Coronary vein stenoses or an insufficient vessel caliber can preclude transvenous placement of coronary vein leads. METHODS: We compared our total patient population (n = 218), in whom we implanted coronary vein leads, to those five patients who required coronary vein angioplasty to allow lead placement. Standard over-the-wire coronary artery balloon angioplasty catheters were used to dilate the vessel to 2.5 mm (n = 3) or 3.5 mm (n = 2). RESULTS: Transvenous lead placement succeeds in >99% of patients. Four cases of target vein stenoses and one case of a vein of insufficient caliber were successfully treated by balloon angioplasty. There were no complications. CONCLUSIONS: Coronary vein angioplasty is an effective and safe technique to permit transvenous left ventricular pacing lead insertion in cases of target vein stenoses or insufficient target vein caliber.     

A New Technique for the Transvenous Implantation of the Over-the-Wire Left Ventricular Pacing Lead in a Patient with Heart Failure

Implantation of left ventricular leads (LV) for biventricular pacing remains a technological challenge and failure of the procedure is not uncommon. We described a 58 year-old patient with heart failure and intraventricular conduction delay where difficulty is encountered when cannulating the coronary sinus by the guiding catheter. By placing a guiding catheter in the inferior portion of the right atrium, a coronary guidewire, preloaded with an over-the-wire lead system, was used to reach the lateral cardiac vein. This may help to reduce the implant failure rate and avoid other more invasive means of LV lead implantation.     

Exchange of pacing or defibrillator leads following laser sheath extraction of non-functional leads in patients with ipsilateral obstructed venous access

Occlusion of the subclavian or brachiocephalic vein in pacemaker or defibrillator patients prohibits ipsilateral implantation of new leads with standard techniques in the event of lead malfunction. Three patients are presented in whom laser sheath extraction of a non-functional lead was performed in order to recanalise the occluded vein and to secure a route for implantation of new leads. This technique avoids abandoning a useful subpectoral site for pacing or defibrillator therapy. The laser sheath does not affect normally functioning leads at the same site.


Keywords: laser sheath; venous occlusion; pacemaker; lead extraction