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Tagliari AP, Kochi AN, Mastella B, Saadi RP, di Leoni Ferrari A, Dussin LH, de Moura L, Martins MR, Saadi EK, Polanczyk CA. Ultrasound-guided Axillary Vein Puncture in Cardiac Lead Implantation: Time to Move to a New Standard Access? Arrhythm Electrophysiol Rev 2020; 9:78-82. [PMID: 32983528 PMCID: PMC7491067 DOI: 10.15420/aer.2020.17] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Cardiac stimulation therapy has evolved significantly over the past 30 years. Currently, cardiac implantable electronic devices (CIED) are the mainstream therapy for many potentially lethal heart conditions, such as advanced atrioventricular block or sustained ventricular tachycardia or fibrillation. Despite sometimes being lifesaving, the implant is surgical and therefore carries all the inevitable intrinsic risks. In the process of technology evolution, one of the most important factors is to make it safer for the patient. In the context of CIED implants, complications include accidental puncture of intrathoracic structures. Alternative strategies to intrathoracic subclavian vein puncture include cephalic vein dissection or axillary vein puncture, which can be guided by fluoroscopy, venography or, more recently, ultrasound. In this article, the authors analyse the state of the art of ultrasound-guided axillary vein puncture using evidence from landmark studies in this field.
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Affiliation(s)
- Ana Paula Tagliari
- Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Cardiovascular Surgery Department, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,University Hospital of Zurich, University of Zurich, Cardiac Surgery Department, Zurich, Switzerland
| | - Adriano Nunes Kochi
- Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil.,Centro Cardiologico Monzino, Heart Rhythm Center, Milan, Italy
| | - Bernardo Mastella
- Cardiovascular Surgery Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Rodrigo Petersen Saadi
- Cardiovascular Surgery Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Andres di Leoni Ferrari
- Cardiovascular Surgery Department, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luiz Henrique Dussin
- Cardiovascular Surgery Department, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Cardiovascular Surgery Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Leandro de Moura
- Cardiovascular Surgery Department, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Cardiovascular Surgery Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Márcio Rodrigo Martins
- Cardiovascular Surgery Department, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Cardiovascular Surgery Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Eduardo Keller Saadi
- Cardiovascular Surgery Department, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Cardiovascular Surgery Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Carisi Anne Polanczyk
- Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Cardiology Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Tagliari AP, Kochi AN, Mastella B, Saadi RP, di Leoni Ferrari A, Saadi EK, Polanczyk CA. Axillary vein puncture guided by ultrasound vs cephalic vein dissection in pacemaker and defibrillator implant: A multicenter randomized clinical trial. Heart Rhythm 2020; 17:1554-1560. [DOI: 10.1016/j.hrthm.2020.04.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/12/2020] [Accepted: 04/18/2020] [Indexed: 10/24/2022]
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3
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Bhattacharyya PJ, Agrawal S, Barkataky JC, Bhattacharyya AK. Medial subclavicular musculotendinous complex and insulation break: Rare cause of late pacemaker lead malfunction. Indian Heart J 2016; 67 Suppl 3:S89-91. [PMID: 26995445 PMCID: PMC4798979 DOI: 10.1016/j.ihj.2015.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 07/07/2015] [Indexed: 11/28/2022] Open
Abstract
Insulation break in a permanent pacemaker lead is a rare long-term complication. We describe an elderly male with a VVIR pacemaker, who presented with an episode of presyncope more than 3 years after the initial implantation procedure, attributed to insulation break possibly caused by lead entrapment in components of the medial subclavicular musculotendinous complex (MSMC) and repeated compressive damage over time during ipsilateral arm movement requiring lead replacement. The differential diagnosis of a clinical presentation when pacing stimuli are present with failure to capture and the role of the MSMC in causing lead damage late after implantation are discussed.
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Affiliation(s)
| | - Shweta Agrawal
- DM Resident, Department of Cardiology, Gauhati Medical College, Assam, India
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Complications and Risk Assessment of 25 Years in Pediatric Pacing. Ann Thorac Surg 2015; 100:147-53. [PMID: 25980596 DOI: 10.1016/j.athoracsur.2014.12.098] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/09/2014] [Accepted: 12/23/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children who require cardiac pacemaker implantation have presented a small patient sub-population since the breakthrough of this technology in the 1950s and 1960s. Their small bodies result in a technical challenge for the operating surgeon and put the patient at risk for a series of specific complications. Our study aims to analyze complications and to identify risk factors of endocardial and epicardial pacemaker systems in children. METHODS All pacemaker-related operations in pediatric patients up to the age of 18 years from 1985 through 2010 were retrospectively evaluated. Demographic data including age, height, and weight were recorded. Idiopathic and postoperative dysrhythmias were analyzed separately. RESULTS A total of 149 pacemaker operations were performed in 73 patients. Thirty-two patients did not have a previous cardiac operation. Indications for revision included box exchange, lead-related problems, pacemaker pocket complications, impaired left ventricular function, and pectoral muscle stimulation. Increased pacing thresholds occurred in 17.2% of the patients with epicardial leads compared with 2.9% in the endocardial group. Aside from threshold-related revision, lead problems are more common in the endocardial group (30.4% vs 17.2%). Venous thrombosis occurred in 13.7% of the patients (only endocardial), preferentially (25%) in the weight group less than 15 kg and in idiopathic patients (15.6% vs 10.5% with prior cardiac surgery). CONCLUSIONS Cardiac pacing is particularly challenging in the pediatric patient population facing a large number of reoperations during their lifetime. The lack of clear superiority of either epicardial or endocardial pacing systems requires an individual concept.
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Yang F, Kulbak G. A new trick to a routine procedure: taking the fear out of the axillary vein stick using the 35° caudal view. Europace 2015; 17:1157-60. [DOI: 10.1093/europace/euv066] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/25/2015] [Indexed: 11/13/2022] Open
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Giudici MC, Barold SS. Should the trend toward smaller lead sizes with pacemakers and defibrillators be reconsidered? Expert Rev Cardiovasc Ther 2012; 10:1337-9. [PMID: 23244353 DOI: 10.1586/erc.12.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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7
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Lau EW. Upper Body Venous Access for Transvenous Lead Placement?Review of Existent Techniques. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:901-9. [PMID: 17584273 DOI: 10.1111/j.1540-8159.2007.00779.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Recent developments in permanent pacemaker and implantable cardioverter-defibrillator therapy have focused on the endocardial placement sites of leads ("selective site pacing"), detection and pacing algorithms, and indications for device therapy. In comparison, the surgical and venous access aspects of device therapy have received relatively little attention. Obtaining central venous access is a prerequisite for delivering device therapy through transvenously placed leads. This article reviews the different techniques available for obtaining upper body venous access for transvenous lead placement, even though the information will also be relevant to other specialties that require central venous access for other purposes.
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Affiliation(s)
- Ernest W Lau
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK.
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8
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Dixit S, Marchlinski FE. Cardiac Pacemakers. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Chen JY, Chang KC, Lin KH, Lin YC, Lee JD, Huang SKS. Ultrasonographic Predictors of Unsuccessful Cephalic Vein Approach During Pacemaker or Defibrillator Lead Implantation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:706-11. [PMID: 16884505 DOI: 10.1111/j.1540-8159.2006.00423.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The cephalic vein approach is a preferred route for endocardial lead implantation; however, it is associated with a significant failure rate. Anatomic abnormalities likely play an important role, but specific features have not been well characterized. METHODS Color Doppler ultrasonography was performed in 82 consecutive patients prior to endocardial lead implantation. Venous diameter, depth, flow velocity, and morphology were evaluated and comparisons made between the successful and failed implantations at various stages of the procedure. RESULTS Endocardial lead implantation was unsuccessful in 14 patients (17%), with eight patients of venous isolation failure, 4 patients of cannulation failure, and 2 patients of guidewire crossing failure. Venous diameter was found to be the only independent predictor for isolation and implantation failure. The best cutoff value of cephalic venous diameter to predict unsuccessful cephalic venous approach was < or = 2.2 mm. In total, there were 10 patients with extensive cephalic vein tortuosity. In seven of these 10 patients, the incidence of standard guidewire crossing failure was significantly higher than that without a tortuous cephalic vein (7/10 vs 6/60, P < 0.001). After switching to a hydrophilic guidewire, crossing and navigation were successful in five of the seven patients. CONCLUSIONS Color Doppler imaging is useful to identify cephalic vein characteristics. A small venous diameter is the ultrasonographic predictor for failure of cephalic vein approach. A tortuous venous morphology is associated with a high incidence of guidewire crossing failure, which can be mostly overcome by using a hydrophilic guidewire.
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Affiliation(s)
- Jan-Yow Chen
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
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Camous JP, Raybaud F, Lesto I, Benoit PH. Introduction of Permanent Cardiac Stimulation/Defibrillation Leads Via the Retro‐Pectoral Veins. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:324-5. [PMID: 15826267 DOI: 10.1111/j.1540-8159.2005.09400.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
When the cephalic vein route is not easily accessible for the introduction of permanent stimulation/defibrillation leads, retro-pectoral veins can be looked for, which are usually present and suitable in most patients. As with the cephalic vein route, it is a safer approach than direct subclavian vein puncture. Moreover, using a guidewire and a split introducer increases the rate of successful cannulation.
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Affiliation(s)
- J P Camous
- Department of Cardiology, Faculty of Medicine, University of Nice Sophia Antipolis, France.
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11
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Chen JY, Chang KC, Lin YC, Chou HT, Hung JS. Pre-Procedure Duplex Ultrasonography to Assist Cephalic Vein Isolation in Pacemaker and Defibrillator Implantation. J Interv Card Electrophysiol 2005; 12:75-81. [PMID: 15717155 DOI: 10.1007/s10840-005-5844-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2004] [Accepted: 09/28/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Difficulty in isolating the cephalic vein contributes to failed pacemaker and intracardiac cardioverter-defibrillator (ICD) implantation via the cephalic venous approach. The deltopectoral groove is used as a rough landmark, but the vein is often not found here. We evaluated the benefit of pre-procedural duplex ultrasonography in isolating the cephalic vein. METHODS We enrolled 80 consecutive patients undergoing new pacemaker or defibrillator implantation and performed duplex ultrasonography to localize the cephalic vein before implantation. The corresponding surface location in the infraclavicular region and the depth of the cephalic vein were identified and recorded if the vein was well visualized. Using the imaging results, we dissected the skin over the predicted location until the cephalic vein was isolated. We determined the depth and corresponding surface location of the proximal cephalic vein during surgery. Afterward, we compared localization of the vein using imaging, surgery, and the deltopectoral-groove method. The relationship between cephalic vein depth and body parameters was also evaluated after the procedure. RESULTS All proximal cephalic veins were successfully isolated under the assistance of pre-procedural duplex ultrasonography. When the corresponding surface locations were compared, the location depicted on sonograms was closer to the surgical finding than the location determined by using the deltopectoral-groove method (0.5 +/- 3.9 vs. 4.9 +/- 9.6 mm; P < .001). The depth of the cephalic vein derived from duplex sonograms showed excellent correlation with the surgical findings (r = 0.93, P < 0.001). The cephalic vein depth and body mass index (BMI) also showed a linear relationship with good correlation (r = 0.70, P < 0.001). CONCLUSION Pre-procedural duplex ultrasonography helped in localizing the proximal cephalic vein and isolating the cephalic vein. Surface localization of the proximal cephalic vein was superior with sonography than with the deltopectoral-groove method. There was a linear relationship with good correlation between BMI and cephalic vein depth.
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Affiliation(s)
- Jan-Yow Chen
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
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Chen JY, Chang KC, Lin YC, Chou HT, Hung JS. Feasibility and accuracy of pre-procedure imaging of the proximal cephalic vein by duplex ultrasonography in pacemaker and defibrillator implantation. J Interv Card Electrophysiol 2004; 10:31-5. [PMID: 14739747 DOI: 10.1023/b:jice.0000011482.58569.74] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Jan-Yow Chen
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
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Da Costa A, Faure E, Romeyer C, Samuel B, Messier M, Lamaud M, Isaaz K. Safe and effective placement of two bipolar silicone leads in the cephalic vein using a hydrophilic guidewire and a split introducer. Pacing Clin Electrophysiol 2000; 23:2065-7. [PMID: 11202248 DOI: 10.1111/j.1540-8159.2000.tb00777.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The cephalic vein (CV) is preferable to the subclavian vein for implanting permanent pacing leads because of fewer complications. Unfortunately, this access is unusable in a substantial number of patients. This prospective study evaluates a technique to increase CV access for the placement of two silicone bipolar leads used in DDD pulse generator implants. A standard cephalic cutdown was performed under local anesthesia and a hydrophilic guidewire (HGW) threaded in the CV. The first (ventricular) bipolar lead was then introduced and positioned. When possible, introduction of the second (atrial) lead followed the same direct access. A failed introduction led to a modified procedure (MP) relying on a "split" introducer (8-9 Fr Plastimed) advanced with a circular motion over the HGW, then removal of the dilator, removal of the HGW, insertion of the pacing lead into the sheath with placement in the right atrium, followed by sheath withdrawal. Over an 18-month period, 90 consecutive patients had DDD pacemakers implanted. The CV was accessible in 76 (84.5%) of 90 patients and the direct introduction of the ventricular lead was obtained in 74 (97.4%) of these. Atrialization proceeded as follows: direct access CV in 14 (18%) of 76 patients, MP access in 54 (71%) of 76 patients, and MP failure in 8 (11%) of 76 patients. Overall, this approach allowed cephalic dual insertion in 68 (89%) of 76 patients. In conclusion, the modified procedure presented in this study allows a dual catheterization with bipolar leads in 89% of patients when a CV is available. This significantly improves the success rate for dual bipolar lead implants in this configuration.
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Affiliation(s)
- A Da Costa
- Division of Cardiology, University Jean Monnet of Saint-Etienne, France.
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Shimada H, Hoshino K, Yuki M, Sakurai S, Owa M. Percutaneous cephalic vein approach for permanent pacemaker implantation. Pacing Clin Electrophysiol 1999; 22:1499-501. [PMID: 10588152 DOI: 10.1111/j.1540-8159.1999.tb00354.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Implantation of permanent pacemaker leads into the cephalic vein within the deltopectoral groove is enhanced by introduction of a flexible guidewire into the brachial vein at the antecubital fossa, which is then advanced to the subclavian vein. The cephalic vein within the deltopectoral groove is easily found by incision with the guidewire as a marker. A pacing lead or leads can be inserted along the guidewire or by using a sheath advanced over the guidewire. The procedure was performed on 32 patients and the pacing leads of 28 procedures (DDD 15, VDD 9 and WI 4) were inserted using the cephalic vein without complications.
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Affiliation(s)
- H Shimada
- Department of Cardiology, Shinonoi General Hospital, Matsundo, Japan
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Parsonnet V, Roelke M. The cephalic vein cutdown versus subclavian puncture for pacemaker/ICD lead implantation. Pacing Clin Electrophysiol 1999; 22:695-7. [PMID: 10353126 DOI: 10.1111/j.1540-8159.1999.tb00531.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
We describe two patients with defibrillation failure of implantable cardioverter defibrillators (ICDs) resulting from large left pneumothoraxes following subclavian vein puncture during the implantation. Following pneumothorax drainage, low defibrillation thresholds (DFTs) were attained without further manipulations. The absence of other signs and symptoms of pneumothorax and the presence of satisfactory pacing function during the procedure, resulted in a significant delay in diagnosis. Pneumothorax should be included in the differential diagnosis when unexpected high DFTs are found during ICD implantation or predischarge testing. This complication is avoidable by a different surgical approach, cephalic vein cutdown.
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Affiliation(s)
- D Luria
- Neufeld Cardiac Research Institute, Tel Aviv University, Israel
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Noguera HH, Peralta AO, John RM, Venditti FJ, Martin DT. Combined use of non-thoracotomy cardioverter defibrillators and endocardial pacemakers. HEART (BRITISH CARDIAC SOCIETY) 1997; 78:50-5. [PMID: 9290402 PMCID: PMC484864 DOI: 10.1136/hrt.78.1.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To study the potential interactions in patients with endocardial permanent pacemakers and non-thoracotomy implantable cardioverter defibrillator (ICD) systems. DESIGN Case series and cohort study. SETTING Tertiary referral centre. PATIENTS Fifteen consecutive patients with both endocardial pacemakers (12 dual chamber and three single chamber) and non-thoracotomy ICD systems. MAIN OUTCOME MEASURES Detection inhibition of induced ventricular fibrillation; double counting; and pacemaker function after shocks. In the evaluation of detection inhibition, 124 VF inductions were analysed for detection duration compared with induced VF episodes in controls with an ICD but without a pacemaker. RESULTS Two patients (13%) showed detection inhibition of VF and required pacemaker system change at the time of the ICD implant. With the final lead position, despite frequent pacemaker undersensing of VF, ICD detection of VF was not inhibited during any induction, and neither initial detection nor redetection times for VF were different from controls. Double/triple counting of pacemaker artefact and evoked electrogram was noted in three patients (20%). In two, this was remedied during the implantation procedure, and in the other it was abolished when amiodarone treatment was discontinued. Pacemaker function was affected by ICD discharges in two patients, one who showed postshock atrial undersensing and loss of capture, and another whose pacemaker reverted to VVI mode. CONCLUSIONS When careful testing is performed at implantation to detect and remedy device interactions, non-thoracotomy ICD treatment and endocardial pacemakers can be used safely in combination.
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Affiliation(s)
- H H Noguera
- Cardiac Electrophysiology Laboratory, Lahey-Hitchcock Medical Center, Burlington 01805, USA
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Roelke M, O'Nunain SS, Osswald S, Garan H, Harthorne JW, Ruskin JN. Subclavian crush syndrome complicating transvenous cardioverter defibrillator systems. Pacing Clin Electrophysiol 1995; 18:973-9. [PMID: 7659570 DOI: 10.1111/j.1540-8159.1995.tb04737.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED Subclavian crush syndrome, described with pacemaker leads implanted via subclavian puncture, may occur when conductor fractures and insulation breaches develop by compression of a lead between the first rib and clavicle. We reviewed our experience in 164 patients who underwent intended implantation of transvenous defibrillator systems to determine the clinical relevance of subclavian crush syndrome in defibrillator patients. Venous access was obtained via subclavian puncture in 114 patients (70%) and via cephalic cut-down in 50 patients (30%). Nonthoracotomy lead systems, with or without subcutaneous patch, were successfully implanted in 131 of 164 patients (79.9%). Thoracotomy was required in 32 patients (19.5%) and subxiphoid patch in 1 patient (0.6%). Over a mean of 12.9 months (range 1-62 months), 3 patients (1.8%) required revision of the rate sensing lead/coil or superior vena cava coil after development of lead compression fractures in the region of the clavicle and first rib. In all 3 patients the leads had been implanted via subclavian puncture (2.6% of patients in whom the subclavian technique was utilized). Two patients presented with spurious shocks. One patient was asymptomatic. CONCLUSIONS When venous access is obtained via subclavian puncture, subclavian crush syndrome may develop in patients with transvenous defibrillator systems. Patients may be asymptomatic and lead fractures may go unrecognized. When implanting transvenous defibrillator systems, strong consideration should be given to obtaining venous access primarily via the cephalic cut-down technique.
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Affiliation(s)
- M Roelke
- Division of Cardiology, Newark Beth Israel Medical Center, New Jersey
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Roelke M, McNamara D, Osswald S, Semigran M, Dec W, Harthorne JW. A comparison of VVIR and DDDR pacing following cardiac transplantation. Pacing Clin Electrophysiol 1994; 17:2047-51. [PMID: 7845816 DOI: 10.1111/j.1540-8159.1994.tb03798.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
UNLABELLED We compared the clinical course of patients paced in VVIR versus DDDR mode to determine the most appropriate method of pacing following cardiac transplantation. Pacemaker implantation was required in 9 of 90 orthotopic cardiac transplants (10%). Indications included sinus bradycardia or sinus arrest (8 patients) and AV node dysfunction (1 patient). VVIR pacemakers were implanted in four patients and DDDR in five patients. DDDR patients: The mean P wave was 1.7 mV and the mean atrial stimulation threshold was 0.8 V (at 0.5 msec). During follow-up of 20 months, two atrial lead complications developed (29% of leads in 33% of patients). No lead complications were directly related to endomyocardial biopsy. VVIR patients: All four patients developed VA conduction with mean VA time 180 msec (160-240 msec). Two patients developed pacemaker syndrome. CONCLUSIONS VA conduction and pacemaker syndrome may develop in cardiac transplant recipients paced in the VVIR mode. Dual chamber pacing is technically feasible and preferable following cardiac transplantation.
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Affiliation(s)
- M Roelke
- Cardiac Unit, Massachusettes General Hospital, Boston 02114
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Abstract
Submammary pacemaker implantation offers women a cosmetically acceptable alternative to the standard pectoral implant. We present a novel method of submammary implantation performed on ten women aged 13-54 years. The lead electrodes are tunneled from the infraclavicular to the inframammary incision using a long needle, guidewire, and introducers/dilators in a manner analogous to the retained guidewire technique used for standard lead insertion. The procedure can generally be performed under local anesthesia. All patients tolerated the procedure well without acute complications. Over 2- to 23-month follow-up, there were no lead dislodgments. No patients developed mastitis or incisional complications, and all have been extremely satisfied with the cosmetic results. With proper technique, submammary pacemaker implantation can be performed under local anesthesia with minimal patient discomfort and optimal cosmesis.
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Affiliation(s)
- M Roelke
- Pacemaker Laboratory, Massachusetts General Hospital, Boston 02114
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Fröhlig G, Schwaab B, Schwerdt H, Lawall P, Trendelenburg M, Schieffer H. A new steroid-eluting screw-in electrode. Pacing Clin Electrophysiol 1994; 17:1134-42. [PMID: 7521039 DOI: 10.1111/j.1540-8159.1994.tb01471.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A new lead design was tested that combined a small microporous steroid-eluting electrode with an insulated, exposed helix for active fixation. This lead (model 5078, Medtronic, Inc., group I, n = 10) was compared to a conventional model (model Y 60 BP, Biotronik) with a larger surface of polished platinum-iridium, equipped with a fixed, noninsulated screw but without steroid elution (group II, n = 10). The two lead models were studied in the atrial position of dual chamber pacing systems, which all had a tined ventricular lead (model 5024, Medtronic, Inc.), with essentially the same steroid-eluting tip as the new active fixation lead design. Sensing and pacing data were recorded acutely and during 1 year of follow-up, via the telemetry of a Relay pulse generator (Intermedics, Inc.). Intraoperatively, unfiltered atrial electrogram amplitudes did not differ between groups (group I: 7.12 +/- 2.56 mV vs group II: 6.42 +/- 1.87 mV; P > 0.05), nor did sensing thresholds 1 year after implantation (group I: 5.33 +/- 1.70 mV vs group II: 4.26 +/- 1.40 mV; P > 0.05). Atrial pacing thresholds as measured during surgery at a pulse width of 0.5 msec were lower in group I (0.49 +/- 0.15 V) than in group II (0.68 +/- 0.19 V; P < 0.05). From day 5 through day 360 of follow-up, the difference in atrial pacing thresholds was highly significant (P < 0.01), with a smaller peaking of early thresholds and a much lower scattering of data for the steroid screw-in leads than for controls.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G Fröhlig
- Medizinische Universitätsklinik III, Homburg, Germany
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Stamato NJ, O'Toole MF, Valguisti E, Enger EL. A technique utilizing a steerable hydrophilic guidewire for permanent pacemaker implantation. Pacing Clin Electrophysiol 1992; 15:1244-7. [PMID: 1383983 DOI: 10.1111/j.1540-8159.1992.tb03134.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- N J Stamato
- Midwest Cardiovascular Institute, Midwest Heart Research Foundation, Lombard
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24
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Gheissari A, Hordof AJ, Spotnitz HM. Transvenous pacemakers in children: relation of lead length to anticipated growth. Ann Thorac Surg 1991; 52:118-21. [PMID: 2069438 DOI: 10.1016/0003-4975(91)91431-t] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although transvenous pacing is feasible in infants and children, uncertainty remains as to how to allow for future growth at the time of lead insertion. Accordingly, we retrospectively reviewed the relation between age and transvenous lead length. Standard posteroanterior chest roentgenograms were reviewed for 26 patients with transvenous pacemakers inserted at Babies Hospital and Presbyterian Hospital between 1985 and 1989. Sixteen of these were children (age range, 0.75 to 15 years) and 10 were adults (age range, 27 to 90 years). The intravascular length of right ventricular pacing leads was measured as projected on the roentgenogram. In 10 children, the presence of lead loops in the right atrium required the lead length that would have resulted from conventional placement to be estimated. Results for right ventricular pacing lead lengths were correlated with age using linear regression analysis. Average uncorrected lead length measured on the roentgenogram was 345 +/- 35 mm (standard deviation) in adults and 222 +/- 51 mm in children. The use of right atrial loops increased implanted lead length by an estimated 79 mm, from 188 +/- 26 to 267 +/- 43 mm. The difference between lead length in children and adults was analyzed. Approximately 190 mm of additional right ventricular pacing lead in infants and 100 mm in 10-year-old children was needed for growth to adult size. We conclude that an 80-mm right atrial lead loop will allow 6 to 12 years (mean, 8 years) of growth in infants and children without the need for reoperation to adjust lead length.
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Affiliation(s)
- A Gheissari
- Department of Surgery, Columbia-Presbyterian Medical Center, Columbia University College of Physicians and Surgeons, New York, New York
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Higano ST, Hayes DL, Spittell PC. Facilitation of the subclavian-introducer technique with contrast venography. Pacing Clin Electrophysiol 1990; 13:681-4. [PMID: 1693208 DOI: 10.1111/j.1540-8159.1990.tb02086.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The subclavian-introducer technique is a rapid and easily performed method of obtaining venous access for implanting permanent pacemaker electrodes. Although this technique has facilitated the participation of nonsurgeons in pacemaker implantation, the potential for complications is increased over the venous cutdown approach. This is particularly true in difficult cases, such as those with prior lead implants, venous thrombosis, or anomalous venous return. This article describes the use of contrast venography for facilitating an otherwise "blind" subclavian venipuncture. This method should make use of the subclavian-introducer technique safer.
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Affiliation(s)
- S T Higano
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905
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Abstract
A technique for transvenous pacemaker implantation in children with complex heart disease is described. The use of small positive-fixation leads, introducers, retained guidewires, and atrial lead loops to allow for growth all have an important role in management of this often challenging problem.
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Affiliation(s)
- H M Spotnitz
- Columbia Presbyterian Medical Center, New York, New York
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EMRE ATILA, MCALISTER HUGH, TUZCU EMURAT, MALONEY JAMESD. Comparison of Atrial Leads: Importance of Polarity and Fixation Mechanism. J Interv Cardiol 1989. [DOI: 10.1111/j.1540-8183.1989.tb00764.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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