Lead insertion by supraclavicular approach of the subclavian vein puncture

Vein Management for Cardiac Device Implantation

Transvenous approaches for pacemaker and defibrillator lead insertion offer numerous advantages over epicardial techniques. Although the cephalic, axillary, and subclavian veins are most commonly used in clinical practice, they each offer their own set of advantages and disadvantages that leave their usage dependent on patient anatomy and physician preference. Alternative methods using the upper and lower venous circulation have been described when these veins are not available or practical for lead insertion. Until current technology is superseded by leadless pacing systems, the search for the optimal lead insertion technique continues.

Venous System Interventions for Device Implantation

Subclavian obstruction is common after lead implantation and the need to add or replace a lead is increasing. Subclavian venoplasty (SV) is a safe and effective option for venous occlusion. Peripheral venography overestimates the severity of the obstruction. A wire can usually be advanced into the central circulation for SV. Compared with dilators, SV improves the quality of venous access, providing unrestricted catheter manipulation for His bundle pacing and left ventricular lead implantation. SV preserves venous access and reduces lead burden. SV can easily be added to the implanting physicians lead management options.

Permanent pacing in patients without upper limb venous access: a review of current techniques

Permanent transvenous cardiac pacing is usually accomplished through the upper limb veins. When these are occluded, several other vascular access options exist which include the internal jugular, external jugular, femoral and iliac veins as well as more proximal access of the subclavian veins. Anterograde and retrograde techniques to restore subclavian venous patency has been described. A review of these approaches is undertaken, with a discussion of their pros and cons. Familiarity with these techniques will enable the implanter to perform transvenous pacing when faced with limited vascular access.

Supraclavicular vein approach to overcoming ipsilateral chronic subclavian vein obstruction during pacemaker-ICD lead revision or upgrading

AIMS

We report our experience with the supraclavicular vein approach of subclavian vein puncture to overcome ipsilateral chronic obstruction when implanting pacemaker or implantable cardioverter defibrillator leads.

METHODS AND RESULTS

The subclavian vein obstruction was documented by venography. The skin was punctured with an 18-gauge needle, 1 cm lateral to the lateral head of the sternocleidomastoid muscle and 1 cm cranial to the clavicle. The needle was directed under and close to the clavicle pointing to the sternal notch. Once the vein was successfully punctured, medial to the obstruction, a 0.38 in. guidewire was inserted into the venous bed. A peel-away sheath was indwelled using the Seldinger technique. The leads were placed in the standard fashion; they were secured by suture to the subcutaneous tissue of the fossa supraclavicularis major using a protective sleeve. The proximal portion of the lead was tunnelled over the clavicle down to the device's prepectoral pocket. Lead insertion was performed in four patients (twice in one patient) with total left subclavian vein obstruction; the site of the obstruction was in the mid-segment of the left subclavian vein in two patients, in the axillary and distal segment of the subclavian vein in one patient, and in the distal segment of the subclavian vein in one patient. There were no complications with the surgical wound and the lead parameters remained stable.

CONCLUSION

The supraclavicular approach of the subclavian vein puncture to overcome ipsilateral total occlusion is feasible and safe.

Opening an Occluded Subclavian Vein with a Screw-Like Flexible Hollow Guide-wire and Venoplasty

Patients with existing internal cardioverter defibrillators (ICDs) often require upgrading to a biventricular ICD for treatment of congestive heart failure (CHF). Placement of a left ventricular (LV) lead can be technically challenging in the best of circumstances. A subclavian vein stenosis or occlusion related to previously placed leads adds a major obstacle to a successful implant. We report a technique of implanting an LV lead from the same side as the existing ICD system despite complete occlusion of the subclavian vein.

Upper Body Venous Access for Transvenous Lead Placement?Review of Existent Techniques

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.

Upgrading Patients with Chronic Defibrillator Leads to a Biventricular System and Reducing Patient Risk: Contralateral LV Lead Placement

Increasing numbers of patients with indwelling single- or dual- chamber internal cardioverter defibrillators (ICDs) will require upgrading of an existing system to a biventricular ICD providing cardiac resynchronization with back-up defibrillation. Upgrading, usually by the addition of a new left ventricular (LV) lead, can be technically challenging with central venous occlusion or stenosis often being the main obstacle to a successful procedure. We report a new technique of implanting a LV lead from the contralateral side to the existing ICD system to minimize the peri- and postoperative risk to the patient.

Placement of Transvenous Pacemaker and ICD Leads Across Total Chronic Occlusions

OBJECTIVE

To establish a method of implantation for device leads across total venous occlusions.

BACKGROUND

Indications for pacemaker and implantable cardiac defibrillator implantation continue to expand. Chronic venous occlusions are increasingly encountered with lead placement. Some degree of obstruction can be as high as 13% before device implantation and 50% after transvenous device implantation. We report an approach of venoplasty/dilatation of chronic total occlusions to allow lead placement.

METHODS

From January 1, 2002 through December 16, 2004, 1,356 systems (initial and upgrade) were implanted at the University of Virginia. At the time of device implant, seven patients were noted to have chronic venous occlusions and alternative access was precluded. Four of the seven patients had an existing system; the other three received initial implantations. Subsequently, these seven patients had a 5 Fr catheter placed in the basilic/axillary/subclavian vein and a venogram was obtained to demonstrate the area of chronic occlusion. A guide wire was advanced across the lesion for initial recanalization. Dilatation or venoplasty was performed at the occluded site. A guide wire was retained across the lesion and the patient underwent lead implantation.

RESULTS

In all seven patients, recanalization was achieved and leads were successfully placed. There were no complications or damage to the vessels or existing leads.

CONCLUSIONS

Venoplasty or dilatation of chronic total venous occlusion is a safe and effective technique, which allows for placement of transvenous leads.