Prospective Study of Axillary Vein Puncture with or Without Contrast Venography for Pacemaker and Defibrillator Lead Implantation

Axillary vein puncture may be used to implant pacemaker (PM) or cardioverter defibrillator leads, though usually requires venography. We prospectively compared punctures guided by venography versus a new radiological landmark. In 232 patients, the puncture was guided by injecting diluted contrast material via an ipsilateral peripheral vein (group A, n = 142), or without venography using the intersection of the lateral borders of the second and third rib as a radiological landmark, followed by contrast injection in case of failure (group B, n = 90). We implantated 1–3 leads per patient. In group A, implantation was successful in 135 patients (95%) and in group B in 55 patients (61%, P < 0.001 vs group A). Subsequent contrast injection allowed successful implantations in 34 of 35 patients, with an success rate of 97% for the overall study population of 224 patients. Venous access was achieved after a mean of 10.4 ± 3.2 minutes of skin incision in group A versus 9.4 ± 3.0 minutes in group B (ns). Pneumothorax occurred in two patients (1% overall). Thus non-contrast guided puncture using a new radiological landmark was successful in a majority of patients. This technique may be useful in absence of ipsilateral peripheral vein access, or presence of contrast allergy.     

Iliac Vein Approach to Permanent Pacemaker Implantation

Since July 1980, 90 patients have had 95 permanent pacemakers implanted via an iliac vein approach. An incision is made superior to the inguinal ligament and the iliac vein is cannulated with a single lead for the ventricle or two leads for the atrium and ventricle. The pulse generator is placed in the subcutaneous tissue of the abdomen lateral to the umbilicus via a second incision. Overall 28 pacemaker implants were for atrial pacing, 53 for ventricular pacing and 14 were dual chamber. Nine (21%) of the atrial leads displaced and required repositioning and 5 (7%) of the ventricuiar leads dislodged and required revision. Lead dislogement, especially in the atrium, remains a major weakness of the approach, and decreases its utility. Eleven percent of the last 19 atrial leads have dislodged. Nevertheless, the method is simple to perform and is presented as an alternative to the usual pectoral implantation site.     

Prospective Randomized Comparison of the Safety and Effectiveness of Placement of Endocardial Pacemaker and Defibrillator Leads Using the Extrathoracic Subclavian Vein Guided by Contrast Venography Versus the Cephalic Approach

CALKINS, H., et al. : Prospective Randomized Comparison of the Safety and Effectiveness of Placement of Endocardial Pacemaker and Defibrillator Leads Using the Extrathoracic Subclavian Vein Guided by Contrast Venography Versus the Cephalic Approach. The purpose of this prospective randomized study was to compare the safety and efficacy of the cephalic approach versus a contrast-guided extrathoracic approach for placement of endocardial leads. Despite an increased incidence of lead fracture, the intrathoracic subclavian approach remains the dominant approach for placement of pacemaker and implantable defibrillator leads. Although this complication can be prevented by lead placement in the cephalic vein or by lead placement in the extrathoracic subclavian or axillary vein, these approaches have not gained acceptance. A total of 200 patients were randomized to undergo placement of pacemaker or implantable defibrillator leads via the contrast-guided extrathoracic subclavian vein approach or the cephalic approach. Lead placement was accomplished in 99 of the 100 patients randomized to the extrathoracic subclavian vein approach as compared to 64 of 100 patients using the cephalic approach. In addition to a higher initial success rate, the extrathoracic subclavian vein medial approach was determined to be preferable as evidenced by a shorter procedure time and less blood loss. There was no difference in the incidence of complications. In conclusion, these results demonstrate that lead placement in the extrathoracic subclavian vein guided by contrast venography is effective and safe. It was also associated with no increased risk of complications as compared with the cephalic approach. These findings suggest that the contrast-guided approach to the extrathoracic portion of the subclavian vein should be considered as an alternative to the cephalic approach.     

Safe Introducer Technique for Pacemaker Lead Implantation

Over the last several years, an introducer approach for pacemaker lead insertion has evolved that eliminates most introducer-related complications. The approach consists of defining a safe region for intrathoracic cannulation of the subclavian vein. If specific conditions cannot be met for entering the "safe" region or if the vein cannot be found, the subclavian vein is cannulated extrathoracically. Recently, this technique was used in 263 consecutive patients undergoing pacemaker implantation. The intrathoracic portion of the subclavian vein was used in 239 (90.9%) cases and the extrathoracic portion in 24 (9.1%). One hundred and ninety-eight (75.3%) cases were right-sided and 65 (24.7%) were left-sided. On the right side, 177 (89.4%) used the intrathoracic portion of the subclavian vein and 21 (10.6%) used the extrathoracic portion. On the left side, 62 (95.4%) used the intrathoracic portion and three (4.6%) used the extrathoracic. The introducer technique was successful in all cases and there were no introducer-related complications.     

Venospasm in Contrast Venography-Guided Axillary Vein Puncture for Pacemaker Lead Implantation

CHAN, N.-Y., et al. : Venospasm in Contrast Venography-Guided Axillary Vein Puncture for Pacemaker Lead Implantation. Venospasm is a recognized complication in right heart catheterization and the reported incidence is 2%. Contrast venography guided axillary vein puncture was a recently described technique for pacemaker lead implantation. This report describes a case of venospasm of the axillary vein during pacemaker implantation. (PACE 2003; 26[Pt. I]:112–113)     

Implantation of Cardioverter Defibrillator and Pacemaker Using the Same Pectoral Quadrant

We implanted a cardioverter defibrillator (ICD) together with a pacemaker system in three patients with ventricular tachycardia and bradyarrhythmias. Both systems (ICD and pacemaker) were implanted in the same left pectoral quadrant using a single skin incision and the subclavian and/or the cephalic vein. The ICD was implanted deep to the pectoralis major muscle, the pacemaker was placed subcutaneously in a more medial pocket. There were no technical difficulties during implantation or complications during follow-up.     

Transiliac Vein Approach to a Permanent Pacemaker Implantation After Aortic Valve Reoperation

This article describes the case of a 71 -year-old woman in whom a permanent pacemaker implantation was performed through an iliac vein because of superior vena cava obstruction after aortic valve reoperation. During a 6-month follow-up, the patient did well and the pacemaker performance was satisfactory.     

Inadvertent Implantation of an ICD Lead in the Great Cardiac Vein

We report an implantable cardioverter defibrillator (ICD) implanted with a single lead inadvertently introduced in the great cardiac vein. No venous lesion was caused by the shocks and the position of the lead remained stable. This case emphasizes the usefulness of different fluoroscopic views during ICD implantation.     

Right Ventricular Implantable Cardioverter Defibrillator Lead Implantation Through a Persistent Left Superior Vena Cava

A 60-year-old woman required implantation of an ICD because of a hypotensive ventricular tachycardia refractory to four different antiarrhythmic drugs. Preoperative diagnostics revealed a persistent left SVC as the only major venous return from the upper part of the body to the heart. Under local anesthesia, a tripolar lead was advanced through the left SVC into the right ventricular apex. Following successful testing, an active can ICD device was implanted, which is functioning well during a follow-up period of 9 months.     

Transiliac Vein Approach to a Rate Responsive Permanent Pacemaker Implantation

A 60-year-oId patient was admitted for elective replacement of a depleted pulse generator. The pacemaker was implanted 5 years before because of sick sinus syndrome and it was connected to an epicardial lead due to total occlusion of the superior vena cava. The pacing threshold of the epicardial electrode was unacceptabiy high, so an endocardial lead was inserted through the iliac vein. The lead was connected to a VVIR pacemaker, ivhich was located in the abdomen just lateral to the umbilicus. During a 1-year follow-up period, the patient felt well and pacemaker performance was satisfactory.     

Permanent Pacemaker Implantation Using the Femoral Vein: A Preliminary Report

A permanent pacemaker was implanted through the femoral vein in 23 patients using the percutaneous puncture technique. The pulse generator was placed in the lower abdominal wall. The method is simple and reduces the time necessary to accomplish implantation. Catheter extrusion in one patient was easily corrected. Another patient had late thrombophlebitis, possibly unrelated to the procedure. Catheter dislodgement occurred in four (4) patients and penetration of the right atrial appendage and right ventricular apex each occurred once. We believe these problems can be circumvented with more experience and expect the femoral approach to be a simple and practical method permanent pacemaker implantation.     

Transvenous Pacemaker Insertion Ipsilateral to Chronic Subclavian Vein Obstruction: An Operative Technique for Children and Adults

OVADIA, M., et al. : Transvenous Pacemaker Insertion Ipsilateral to Chronic Subclavian Vein Obstruction: An Operative Technique for Children and Adults. Subclavian vein occlusion limits insertion of pacing electrodes in children and adults. The concern is greatest in children with a long‐term need for pacing systems necessitating use of the contralateral vein and potential bilateral loss of access in the future. We describe an operative technique to provide ipsilateral access in chronic subclavian vein occlusion in five consecutive pediatric (n = 4 , mean age 6.5 years) and adult (n = 1 , age 70 with bilateral subclavian vein occlusion) patients in whom this condition was noted at the time of pacemaker or ICD implant. Occlusion was documented by venography. Pediatric cardiac diagnoses included complete heart block in all patients, tetralogy of Fallot in three, and L‐transposition of the great vessels in one. Percutaneous brachiocephalic (innominate) or deep subclavian venous access was achieved by a supraclavicular approach using an 18‐gauge Deseret angiocath, a Terumo Glidewire, and dilation to permit one or two 9–11 Fr sheaths. Electrode(s) were positioned in the heart and tunneled (pre– or retroclavicularly) to a pre– or retropectoral pocket. Pacemaker and ICD implants were successful in all without any complication of pneumothorax, arterial or nerve injury, or need for transfusion. Inadvertent arterial access did not occur as compared with prior infraclavicular attempts. One preclavicularly tunneled electrode dislodged with extreme exertion and was revised. Ipsilateral transvenous access for pacemaker or ICD is possible via a deep supraclavicular percutaneous approach when the subclavian venous obstruction is discovered at the time of implant. In children, it avoids the use of the contralateral vein that may be needed for future pacing systems in adulthood. This venous approach provides access large enough to allow even dual chamber pacing in children and can be accomplished safely.     

Total Pectoral Implantation: A New Technique for Implantation of Transvenous Defibrillator Lead Systems and Implantable Cardioverter Defibrillator

We describe a new approach to tolal pectoral implantation of cardioverter defibrillators with an endocardial defibrillation lead system. Endocardial lead configuration used was an FDA approved right atrial-superior vena cavo defibriliation spring electrode, right ventricular bipolar sensing electrode, and a pectoral patch. Endocardial leads were implanted via a cephalic or an axillary venesection. Pectoral patch was placed in a sabmuscular position. In case of failure to obtain satisfactory thresholds, a small intercostal thoracofomy was performed via fhe same skin incision and patch placed over the epicardium instead of submuscular position and used with Ihe right atrial spring electrode. The device was implanted in the pectoral region, submuscularly, over the patch. Sixteen consecutive patients underwent this approach. With a submascular patch, adequate defibrillation thresholds (< 15 joules [J]) were obtained in 14 (87.5%) patients. In the other two, defibrillation thresholds of ≤ 15) were obtained with a epicardial patch. Pectoral implantation of the device was feasible in all 16 patients and none needed repositioning. Average postimplant hospital stay was 5 days. During follow-up period (average 5 months), none of the patients reported any major local symptoms and no problems have been encountered in device interrogation. Thus, total pectoral implantation of the cardioverter defibrillator including the patch, leads, and the device is feasible. Furthermore, in case of foilure to obtain adequate defibrillotjon thresholds with submuscular patch, an epicardial patch can easily be implanted and allows 100% successful defibrillation at energy levels of ≤ 15 J with right atrial patch configuration.     

Transvenous Pacemaker Implantation Via a Unilateral Left Superior Vena Cava

A 72-year-old man with a unilateral left superior vena cava and anomalous drainage of the inferior vena cava required permanent pacing. The anomalies were verified by venography and cardiac catheterization. Difficulties in implantation of a temporary and permanent pacemaker are described. A transvenous endocardial lead was placed in a stable position in the right ventricle. The pacemaker system has now functioned normally for 32 months.     

下肢深静脉顺行造影术不同穿刺部位和方法对比研究

目的对比研究下肢深静脉顺行造影术不同静脉穿刺部位和方法的应用效果。方法将224例患者（300例次下肢造影）按检查时间分为观察组和对照组各150例次下肢造影。观察组逆心穿刺内踝旁侧的大隐静脉;对照组向心穿刺拇指基底部旁侧的浅静脉或足背浅静脉。对两组下肢深静脉显影效果、静脉穿刺成功率、患者的疼痛感进行比较。结果两组静脉穿刺成功率、患者的疼痛感比较,差异均有统计学意义（P〈0．01）;下肢深静脉显影效果比较,差异无统计学意义（P〉0．05）。结论下肢深静脉顺行造影术采用逆心穿刺内踝旁侧大隐静脉,可提高静脉穿刺成功率、减轻患者的疼痛且血管显影效果不变。     

Ease of Insertion of Exposed Helical Coil Tip and Tined Silicone Leads Through Single Cephalic Vein

Since polyurethane was introduced as an insulation material for pacing leads, it has been purported that passing two polyurethane leads through one vein would be significantly easier than passing two bipolar silicone leads. However, this case, in which two bipolar silicone leads were easily positioned via a single cephalic vein, raises the question of whether there is any clinically significant in vivo lubricity difference between the two materials.     

A Technique Utilizing a Steerable Hydrophilic Guidewire for Permanent Pacemaker Implantation

We report the use of a steerable hydrophilic guidewire for permanent pacemaker implantation. This wire, previously used for peripheral vascular and cardiac angiography, is able to be steered and passed in many situations when a standard guidewire cannot be used. We report three cases where the standard J-tipped guidewire could not be passed by either the cephalic or subclavian route and the hydrophilic guidewire allowed for successful atraumatic placement of a sheath and pacemaker lead.