置入起搏器手术方法的改进与减少相关并发症

头静脉放置起搏电极导线是最理想的径路 ,与常规分离头静脉做纵向切口相比 ,横切口分离头静脉同样能够良好地暴露该血管。此外 ,当需要穿刺锁骨下静脉时 ,直接经切口内穿刺不但快捷省时 ,而且减少创伤。在头静脉内放置导引钢丝及静脉鞘管后送入电极导线将大大提高成功率。针管内不带盐水穿刺锁骨下静脉 ,并将钢丝送入到下腔静脉是避免误入动脉的重要措施。使用不吸收缝线通过保护袖套 ,将电极导线的近端牢固地缝合在胸大肌上是减少术后电极导线脱位的重要措施之一。用可吸收缝线皮内缝合皮肤 ,术后不需拆线 ,皮肤对合好、瘢痕小 ,而且为早期出院创造了条件。     

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.     

指引导丝引导下经头静脉放置两根起搏导线的临床应用

经头静脉插入起搏导线是理想的选择，因为该方法可以避免穿刺锁骨下静脉带来的术中并发症及长期摩擦导致导线损坏、断裂等并发症。头静脉有管径及走行变异，切开头静脉直接插入两根起搏导线经常失败，需要借助指引导丝及撕开鞘送人起搏导线。目前双腔起搏器植入量明显增多，本文探讨导丝引导下经头静脉放置两根永久起搏导线的有效性及安全陛。     

经头静脉植入双腔起搏器的可行性和安全性

目的:探讨经头静脉切开途径同时置入2根电极行双腔起搏的可行性和安全性。方法:对92例有脑缺血症状的病窦综合征、Ⅱ度Ⅱ型或Ⅲ型房室传导阻滞患者,常规经右头静脉切开途径行双腔起搏治疗,了解其成功率,并随访1-36个月,观察其术后并发症情况。结果:71例(77.2％)患者直接成功植入双腔起搏器,12例(13％)患者经超滑导丝引导置入静脉鞘管后成功引入,故共83例(90.2％)患者经头静脉切开成功植入,较直接植入成功率显著增高(P<0.01);9例患者(9.8％)改经右锁骨下静脉穿刺途径植入。随访期间经头静脉途径植入起搏器的83例(100％)患者术后局部切口愈合良好,均未见电极移位或断裂,且脑缺血症状均消失。结论:经头静脉切开途径行双腔起搏治疗成功率较高,简便、安全,可推广应用。     

上腔静脉窦状扩张致右锁骨下静脉途径起搏失败1例

患者 ,男 ,71岁。因病态窦房结综合征频繁阿 -斯综合征发作于 1 999年 5月 2 7日行永久性心脏起搏器安置术。局麻下行右锁骨下静脉穿刺成功 ,导引钢丝顺利送至右心房到下腔静脉 ,沿导引钢丝送入 F8扩张鞘管 ,至上腔静脉起始部左侧壁 ,扩张鞘管不能沿导引钢丝向下至上腔静脉 ,且将导引钢丝折成直角 ,反复试送均未成功 ,撤出导引钢丝 ,注入少量造影剂显示 :上腔静脉起始部左侧壁形成一窦状扩张。于是放弃该途径改为经左锁骨下静脉穿刺途径 ,扩张鞘管及起搏电极导线送入均顺利 ,手术成功 ,观察 2周 ,患者痊愈出院。1齐鲁石油化工公司中心医院…     

经狭窄上腔静脉植入起搏系统一例

患者男性,36岁。半年前因起搏器电池耗竭在外院更换新起搏导线时发现上腔静脉入口处几近阻塞而放弃手术。笔者尝试穿刺左锁骨下静脉后在鞘管内送入超滑亲水导丝并顺利经过上腔静脉狭窄处进入右心系统,撤出普通的鞘管及扩张管并换用左室递送系统沿导丝成功穿过上腔静脉狭窄处,撤出扩张鞘,自鞘管内送入心室电极导线至右室心尖部固定及起搏参数均满意的部位。术中及术后无并发症发生。提示应用超滑钢丝结合长鞘通过狭窄的静脉送入心室电极导线,在临床上需要时是可以尝试的方法。     

如何优化起搏植入术的流程

优化起搏植入术的流程很重要。对普通起搏器,先切开皮肤到筋膜层后再在有空隙的锁骨下间隙进行穿刺;鞘管在送入导线至静脉后应撤除;房、室导线均放置好后一并进行起搏测试;囊袋的制作应在导线到位前用双食指钝性分离完成;对已满足要求内的起搏参数不必反复过于"精确"的测试;应轻轻回拉电极导线感觉是否遇到阻力来判断其牢靠固定度;缝合囊袋前应常规透视导线位置;囊袋局部压迫对防止术后囊袋积血很有效。除颤阈值试验测试过程中要分工协作。心脏再同步化治疗植入手术时要密切观察病情变化;应分别根据右房大小和靶静脉特点选择鞘管和左室导线;造影时可稀释造影剂并在远端静脉显影后松开造影球囊以利显示近端静脉;通常先放置左室导线;多可首先应用左室电极导线自带的钢丝直接尝试进入靶静脉;在保留左室鞘管时完成囊袋制作、右房室导线植入;撤鞘时应一气呵成。     

上腔静脉窦阻碍经右锁骨下静脉插入起搏电极一例

患者男性、８０岁。因病窦综合征于１９９８年３月２日接受永久性起搏器治疗。局麻下做好右胸囊袋后,于切口内行锁骨下静脉穿刺,导引钢丝至上腔静脉入口处时只向头侧弯曲。将钢丝头端弯成弧形,多次调整角度,钢丝呈锐角进入上腔静脉。沿钢丝送入扩张管及鞘管,至钢丝折...     

经腋静脉和锁骨下静脉途径置入起搏器电极导线的对照研究

目的通过与锁骨下静脉穿刺置入起搏电极进行对照研究,探讨经腋静脉穿刺置入起搏器电极导线的可行性与安全性。方法入选118例起搏器植入患者,按简单随机法分为腋静脉组(n=66)与锁骨下静脉组(n=52),分别经腋静脉途径和经锁骨下静脉途径置入起搏导线。比较两种途径置入起搏导线的穿刺成功率和并发症。结果腋静脉组与锁骨下静脉组穿刺成功率分别为95.4%(63/66)和96.2%(50/52);两组并发症发生率分别为1.5%(1/66)和5.8%(3/52),两组患者穿刺成功率和并发症发生率均无统计学差异(P均0.05)。其中,锁骨下静脉组发生气胸3例,腋静脉组无一例发生气胸(P0.05)。结论经腋静脉途径置入心脏起搏器导线安全可行。     

股静脉穿刺置管时导引钢丝滑脱入股静脉一例

患者女性、18岁。因左侧旁道反复发作阵发性室上性心动过速于2000年4月18日行射频消融治疗。术中常规穿刺左侧锁骨下静脉插入冠状窦电极后,于右股静脉穿刺放入导引钢丝。在插入静脉扩张管及鞘管的过程中术者注意力不集中,当静脉扩张管及鞘管插入2/3时发现导引钢丝尾端没有露出体外。当时由于术者紧张未及时透视查看导引钢丝在鞘管内的位置,认为将静脉扩张管及鞘管拨出时可将导引钢丝带出体外,按习惯动作拨出静脉扩张管及鞘管时导引钢丝并未带出,而是遗留在体内。此时透视发现导引钢丝尾端距穿刺口约2ｃｍ,当时经局部扩大切口分离组织未能找…     

Modified cephalic vein guide wire technique for permanent pacemaker implantation.

This report describes a modified cephalic vein guide wire technique used for implantation of 18 consecutive pacemakers using bipolar leads. The modified technique appears to be a safe and simple procedure for single chamber permanent pacing. Its use may also be extended in implanting dual chamber pacemakers.     

Implantation of permanent cardiac pacing electrodes by the retropectoral transvenous approach. Results of a series of 152 cases

When the cephalic vein is unsuitable for the introduction of pacing electrodes, the retropectoral veins near the external border of pectoralis major near its subclavian attachment, approached through the same incision, may provide a suitable alternative. It was not possible to catheterise the cephalic vein in 23,8% of 756 consecutive implantations of endocavitary pacing electrodes. The retropectoral veins were looked for in 172 cases and found and used in 159 cases (92,4%). This percentage of success increased to 97,6% in the latter 83 attempts. These veins are usually very distensible. No complications or accidents were recorded. The only disadvantage was the relatively long dissection time. The stability of the pacing electrodes with this approach was excellent as reoperation was only required in 3% of cases (2 displacements and 3 exit blocks or pericardial migrations). This approach is therefore practicable in the large majority of cases in which the cephalic vein cannot be used. The multiplicity of the retropectoral veins should allow the introduction of two electrodes if sequential atrioventricular pacing were to be chosen. In addition, this approach would be useful when an atrial pacing electrode is to be added to a preexisting ventricular pacing electrode and one hesitates to puncture the subclavian vein because of the risk of damaging the electrode already in place. When direct subclavian puncture is the technique of choice of the operator, the retropectoral veins may be used when the subclavian approach is contraindicated or impossible. In any case, denudation of the retropectoral veins leads to fewer incidents than when the latter approach is used.     

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.     

Extraction and Replacement of Permanent Pacemaker Leads Through Occluded Vessels: Use of Extraction Sheaths as Conduits - Balloon Venoplasty as an Adjunct

Patients (pts) may present for lead extraction with symptomatic or asymptomatic subclavian vein or superior vena cava thrombosis. Replacement of permanent pacemaker leads (PPLs) in these pts may be difficult and may require accessing a new site. We examined the utility of replacing PPLs through completely occluded vessels using extraction sheaths as conduits through the total occlusion.Over six years, a total of 210 atrial and/or ventricular PPLs were extracted from 137 pts. Two pts presented with angiographically documented thrombotic occlusion of the subclavian vein. One additional pt, who had presented with a superior vena cava (SVC) syndrome, had a totally occluded innominate vein and SVC occlusion. Balloon venoplasty was used as an adjunct to dilate the SVC.In all pts, after PPLs were removed via a subclavian extraction sheath through the occluded vessel, the retained sheath was used to place a guide wire, then a peel away dilating sheath, to insert new PPLs, in each case on the side of total venous occlusion. Seven PPLs and two lead fragments were extracted, and five new PPLs replaced, ipsilateral to the venous occlusion.These data show that extraction of PPLs through thrombosed veins may be performed successfully and may not require replacing the leads through a new site. This technique spares the pt the need to access the opposite subclavian vein, and it avoids an excessive number of PPLs in the subclavian vein and SVC. The procedure illustrates an efficient means to reintroduce new PPLs with the potential to reduce associated morbidity, since repeat puncture of the subclavian vein is not required. Safety of the procedure as a whole must be considered with regard to the known risks of lead extraction, some complications of which may be substantial using current techniques.     

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.     

Venous thrombosis after long-term transvenous pacing in the Chinese

To determine the incidence of venous thrombosis after long-term transvenous pacing in the Chinese, venograms were performed in 50 consecutive Chinese patients seen at the pacemaker clinic. There were 25 women and 25 men. The mean age was sixty-six years (range thirty-two to eighty-one). The indications for pacing were complete heart block in 16 patients and sick sinus syndrome in the remainder. All pacemakers were of the single-chamber ventricular pacing type and had been implanted for a mean period of four years (range two to seven). In 27 patients the route of entry for the pacing electrode was through the cephalic vein and in the other 23 patients the subclavian veins were used. Of the 50 venograms, 1 showed partial and 1 showed total obstruction at the subclavian vein. Both patients (4%) were asymptomatic. All others (96%) were normal. The incidence of venous thrombosis was not related to the routes of entry of the pacing electrodes. All patients tolerated the procedure well and had no complications. It is concluded that the incidence of venous thrombosis after long-term transvenous pacing is extremely low in the Chinese (4%), and venograms are both safe and useful for identifying venous thrombosis related to transvenous pacing.     

29例起搏器和置入式心脏复律除颤器导线断裂的临床分析

目的分析心脏起搏器和置入式心脏复律除颤器(ICD)导线断裂可能的原因、部位和处理方法。方法回顾性分析1982年1月至2004年11月置入的永久起搏器和ICD,通过随访症状、程控测试、检查X线胸片及心电图,及时发现导线断裂,给予相应处理,并随访观察疗效。结果分析置入的起搏器4698台和ICD161台,共发现导线断裂29例、导线31支,发生率0.6%;其中经锁骨下静脉置入组导线断裂发生率0.9%,头静脉置入组0.4%,P=0.04。断裂部位锁骨下22例,囊袋内6例,心室内1例。29例患者中,24例置入新导线。3例心房导线断裂,将起搏器由DDD程控为VVI工作方式。处理后平均随访(55.6±16.1)个月。1例因保留的断裂导线露出皮肤,引发感染,开胸取出导线。结论起搏器和ICD导线置入应首选头静脉切开途径,其次选择经锁骨下静脉外侧端穿刺置管。导线断裂部位主要发生在锁骨下,定期复查可以及时发现导线断裂,妥善处理。     

Percutaneous implantation of permanent pacemakers (author's transl)

2 methods for the implantation of permanent pacemakers with percutaneous puncture of the subclavian vein are described. The first one was used in 44 patients with the aid of an introducing catheter-set Desilets-Hoffman consisting of guide-wire, inner Teflon dummy catheter and outer thin-walled sheath; through this a shoulder-less electrode catheter no. 8 could be inserted for permanent pacing. The other technique was applied to 20 patients and used thinner special electrodes no. 6F, which could be introduced directly through a plastic cannula inserted with a puncture-needle. The advantages are: diminished risk of infections, local anesthesia instead of general anesthesia, applicability by the cardiologist in the catheterization-laboratory or under a simple fluoroscopy-unit, short stay of patients in the hospital without transfers to other departments, few personnel (1 scrubbed doctor, 1 non-scrubbed nurse), recognition of venous anomalies (singular left superior caval vein) without useless incisions for the patient. Complications such as pneumothorax, puncture of the subclavian artery, and dislocations of the electrodes have also been encountered.     

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%).