静脉畸形、迂曲、狭窄时永久起搏导线置入的方法探讨

经静脉造影或观察导丝走形证实6例患者存在静脉畸形、迂曲、狭窄，其中5例高龄患者置入水久起搏器时，其上腔静脉系统迂曲、狭窄，无法使用起搏器穿刺套装内的导丝及鞘管将导线送到起搏部位，另1例为水存左上腔静脉合并有右上腔静脉缺如。试用175cm—0．035长导丝以及6—8INPUT鞘替代普通起搏器穿刺套装。结果：使用175cm—0．035长导丝以及6—8INPUT鞘顺利地将起搏导线送人右心房中下部，安全地完成置人手术，无并发症。结论：一旦送人导线或导丝困难，应积极地进行血管造影，不应盲目的推送，使用175cm长导丝增加支撑力，结合IN—PUT鞘管通过狭窄或纤曲延长的血管段，给起搏导线提供一个光滑的通道，可顺利的将起搏导线送人心房及心室。     

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。     

左肺缺如患者的心脏起搏器植入二例

两例患者均具备心脏起搏器植入适应证,一例存在左肺发育不全,一例为肺癌左肺全肺切除术后。术中穿刺左侧锁骨下静脉,回血通畅,但J形导丝无法前送,静脉造影显示血管显著迂曲,多处成角。遂改为穿刺右侧锁骨下静脉,但J形导丝仍难以到达下腔静脉。经鞘管送入起搏导线,在推送导线寻找起搏位置的过程中,导线到达心影右侧下端且无室性早搏,考虑导线进入下腔静脉,再经该鞘管送入J形导丝至心影左侧,心电监护出现室性早搏、短阵室性心动过速,回撤导丝室性早搏、室性心动过速消失,考虑导丝进入右室。分别将心房导线送入右心耳,心室导线送入右室心尖部,完成手术。     

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.     

穿刺上腔静脉植入起搏器一例

患者女性，93岁，因完全房室传导阻滞入院。在植入起搏器的过程中，遇到双侧锁骨下静脉迂曲，导丝没能通过。为了绕过迂曲部分，尝试在右侧锁骨中线内侧穿刺，静脉造影显示穿刺针进入了上腔静脉。经讨论后决定，采用上腔静脉植入，手术成功完成，没有围手术期并发症。2个月后随访，起搏器工作良好。提示在通过传统路径植入起搏电极导线困难时，直接穿刺上腔静脉植入是可能的。     

鞘中鞘联合双导丝技术易化左室电极导线植入一例

一例心脏再同步化治疗-除颤器植入患者,术中冠状静脉造影显示左室侧后静脉迂曲,且起始部与冠状静脉主干夹角锐利,导丝难以送入靶静脉。利用鞘中鞘联合双导丝技术,顺利将左室电极导线送入左室侧后静脉,极大的缩短了左室电极导线植入手术时间,减少了射线曝光量。     

经股静脉途径植入永久起搏器一例

1　临床资料　　患者　男性 ,76岁 ,因反复晕厥入院。既往有冠心病、原发性高血压 10余年 ,3年前行冠状动脉旁路移植术。体表心电图及动态心电图检查均显示心房纤颤、Ⅲ度房室阻滞。超声心动图显示左心室扩大 ,左心室射血分数 0 5 8。　　入院后采用右锁骨下静脉途径置入起搏器 ,穿刺成功后多次尝试导引钢丝不能通过上腔静脉到达右心室 ,造影显示上腔静脉严重狭窄病变 ,随采用经下肢股静脉途径。充分局麻后穿刺右股静脉 ,送入 7F动脉鞘管 ,再将MedtronicCap surefix 40 67～ 75cm心室电极置于右心室心尖部 ,测试起搏阈值 :电压 0 5V ,阻…     

永存左上腔静脉伴右上腔静脉缺如患者植入永久心脏起搏器一例

患者女,62岁,心房颤动伴长RR间期,需行永久起搏器植入术,术中行左锁骨下静脉穿刺,放置导丝后发现静脉走行异常,行左锁骨下静脉造影提示永存左上腔静脉;再次穿刺右锁骨下静脉,行右锁骨下静脉造影提示右上腔静脉缺如,再次经左锁骨下静脉置入心室主动固定(螺旋)电极,将电极固定在右室心尖部,起搏阈值正常。     

经髂外静脉途径植入永久起搏器二例报道

例 1,患男 ,32岁 ,因Ⅲ度房室传导阻滞而行ＶＶＩ型人工心脏起搏器植入术。常规穿刺右锁骨下静脉成功后 ,送入鞘管时 ,受阻于锁骨下静脉和上腔静脉注入处。改选髂外静脉植入永久性心脏起搏器。例 2 ,患女 ,81岁 ,心电图示异位心律 ,心房纤颤 ,最长ＲＲ间期达 5 0秒 ,急诊经右侧锁骨下静脉植入心脏起搏器。经过常规右锁骨下静脉穿刺成功后 ,不能送入鞘管及电极 ,经过透视考虑上腔静脉畸形、狭窄。改为髂外静脉途径植入永久性心脏起搏。方法　在腹股沟韧带上方 2 - 3厘米 ,髂外动脉内侧穿刺髂外静脉成功后 ,送入起搏电极至右室心尖部 ,测试各…     

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。     

A successful implantation of a dual-chambers cardioverter defibrillator for a patient with severe tortuous persistent left superior vena cava

We report a case of successful implantation of a dual-chambers transvenous cardioverter defibrillator for a dilated cardiomyopathy patient with severe tortuous persistent left superior vena cava and a very small innominate vein. After confirming the presence of a right superior vena cava, a dilated sheath was advanced into the narrow innominate vein to increase the lumen of innominate vein. The active atrial and ventricular leads were successfully inserted into right atrium and right ventricle through innominate bridge by the support of steerable long sheaths.     

Superior vena cava syndrome after pacemaker implantation. Increased risk with DDD-systems? Case report]

Superior vena cava syndrome due to transvenous pacing leads is a rare event. Local infection as well as multiple leads are important predisposing factors. The case of a patient with superior caval syndrome after multiple complicated permanent pacemaker insertions is presented. Medical treatment was unsuccessful. At operation a fibrous narrowing of the vena cava superior was found. The two leads (DDD-pacemaker) were left in place. A Goretex patch was used for enlargement of the anterior wall of the vein. Postoperatively, the patient remained free of symptoms and the vein was patent angiographically. In case of failure of medical management surgical correction should be attempted without delay.     

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.     

经永存左上腔静脉植入起搏电极体会

目的总结经永存左上腔静脉（PLSVC）植入起搏电极体会。方法总结4例PLSVC植入双腔起搏器的患者。患者出院前及出院后3个月、6个月进行随访,了解起搏器工作状态。结果4例患者术前均常规行经胸超声心动图检查,结果显示冠状静脉窦开口扩大,提示PLSVC存在可能。第1例患者因术前发现PLSVC可能,首先穿刺右侧锁骨下静脉;造影显示右上腔静脉缺如,右侧锁骨下静脉汇入PLSVC。第2、3例患者因双腔起搏器植入前反复出现心动过缓相关症状,在术前经右侧锁骨下静脉植人临时起搏器,术中造影显示PLSVC与右侧上腔静脉无交通。第4例患者在置入导丝时直接经PLSVC进入右心房。患者术后3个月、6个月常规行起搏器程控并调整起搏器出厂设置参数,此后每6—12个月行起搏器程控,程控时测量心房电极和心室电极的起搏阈值、感知和阻抗。均在满意范围。第1例患者两次随访时心律均为窦性心律,心房电极感知大于2mV,起搏阈值小于1V,阻抗小于1000Q。结论PLSVC能够顺利完成起搏电极植入。     

Severe tricuspid valve stenosis secondary to pacemaker leads presenting as ascites and liver dysfunction: a complex problem requiring a multidisciplinary therapeutic approach

Tricuspid stenosis secondary to ventricular pacemaker leads is uncommon. We present a unique case of iatrogenic tricuspid stenosis secondary to fusion of the valve leaflets to transvenous implanted pacing leads. This occurred in an adult with childhood repaired Tetralogy of Fallot and high grade surgical heart block following multiple pacemaker procedures. The case was complicated by superior vena cava (SVC) and innominate vein stenosis secondary to implanted pacing leads, severe tricuspid valve (TV) stenosis, perforation of the heart by one of the implanted transvenous ventricular pacing leads, prolapse of the transvenous atrial pacing lead into the right ventricle, and unusual coronary sinus anatomy. We describe a multidisciplinary approach to management.     

Use of a laser sheath to obtain venous access in pacemaker lead-related obstruction without extraction of the lead.

AIMS: Occlusion of the subclavian vein resulting from pacemaker leads prohibits insertion of new leads. We describe the ipsilateral insertion of a new lead without extracting the old lead using a laser sheath in a pacemaker patient with an obstructed vein. METHODS AND RESULT: A laser sheath together with an outer sheath were advanced over the malfunctioning lead just beyond the occlusion. The laser sheath was pulled back and a guide wire inserted through the outer sheath kept in position distal of the occlusion. After removal of the outer sheath a peel-away sheath was introduced and a new lead implanted next to the malfunctioning lead that was abandoned and not extracted. CONCLUSION: By avoiding using the laser along the whole length of the lead we greatly reduced the risk of the procedure but were still able to recanalize the obstructed vein. A risk of bilateral occlusion is avoided and the contralateral site saved as an entry point for future needs.     

Initial experience in the extraction of chronically implanted pacemaker leads using the Excimer laser sheath

OBJECTIVE: To assess the safety and efficiency of the Excimer laser sheath in extracting chronically implanted pacemaker leads. PATIENTS: Eight patients were studied (one female, mean age 62 years, range 34 to 77) with 17 pacemaker leads (five atrial, 10 ventricular, two implantable defibrillator). The mean implantation time was 65 months (range 23 to 188). The indications for lead extraction were chronic infection (7), superior vena cava obstruction (4), lead malfunction (4), and pain (2). METHODS: A prospective analysis of the use of the Excimer laser sheath in extracting chronically implanted pacemaker leads. Laser sheath extraction was undertaken if conventional extraction techniques with simple traction or traction with a locking stylet had failed. If laser sheath extraction was unsuccessful, basket retrieval of the lead from the groin was performed. RESULTS: Complete lead removal was achieved in 16 leads (94%). In one case the electrode tip was left behind without complication. Extraction was achieved with the laser sheath alone in 16 leads. Basket retrieval was required in one case after laser failure. There were no complications. CONCLUSIONS: The Excimer laser sheath appears to be an effective and safe technique for extracting chronically implanted pacemaker leads. It can be used in combination with the currently available techniques for successful lead extraction.     

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.     

Implantation eines Resynchronisationssystems bei persistierender oberer Hohlvene

We report an implantation of a cardiac re-synchronization system in a patient with persistent left superior vena cava. This anomaly occurs in 0.3 to 0.5% of healthy individuals and remains usually asymptomatic. Variations of the superior vena cava should be considered in venous catheterization and other procedures such as implantation of pacemaker and ICD systems as well as port catheter insertion. In re-synchronization systems, persistent left superior vena cava can be an obstacle for cannulation of the coronary sinus and placement of a transvenous left ventricular lead.     

A novel technique for right ventricular lead placement in a patient with a persistent left superior vena cava.

Persistent left superior vena cava is the most common venous anomaly of the thorax. If unrecognized, it could lead to catheter malplacement and even vascular injuries. We describe a novel use of a Worley sheath for the delivery of a right ventricular (RV) endocardial pacing lead in a 65-year-old male with a persistent left superior vena cava. After failed attempts with the standard stylets, use of the Worley sheath aided successful lead deployment. We conclude that when used appropriately, the Worley sheath is a tool that could be helpful in pacing lead placement in patients with persistent left superior vena cava.