Edmond M. Cronin, MB BCh BAO, Bruce L Wilkoff, MD, Niraj Varma, MA, DM, FRCP
A 28-year-old man with a recent history of resuscitated cardiac arrest and long QT syndrome presents for implantation of an implantable cardioverter-defibrillator (ICD). Given recent media coverage of ICD lead recalls due to increased fracture rates, he asks whether his vulnerability to this problem can be reduced by any mechanism. The discussion includes using leads with a performance record proven over a chronic period and also routes of delivery during surgery.
• Multiple access routes to the heart have been described for implantation of endovascular leads.
• The most commonly used are traditional subclavian vein puncture medial to the clavicle, extrathoracic subclavian or axillary vein puncture under fluoroscopic guidance,1 and cephalic vein cut down.2
• The relative merits of traditional subclavian puncture and cephalic vein cut down have been long debated,3 and all three have advantages and disadvantages (Table 58-1).
TABLE 58-1 Comparison of Cephalic and Extrathoracic Subclavian Access
• A single-center randomized trial comparing cephalic and contrast-guided axillary vein techniques found no difference in early or late complications, but longer procedural time for cephalic vein implantation and implant success of only 64%.4 Operators in this study were inexperienced, however.
• Intrathoracic subclavian vein puncture is discouraged due to the risk of complications including pneumothorax and an elevated likelihood of subclavian crush in between the clavicle and first rib.5
• Recent data from two ICD lead models with accelerated failure rates suggests that cephalic vein implantation may be associated with improved lead survival.6,7 Whether this translates to other lead models is unknown. Slightly higher failure rates with subclavian implantation may be due to improper technique rather than the access route itself.
• The cephalic vein is formed from the dorsal venous arch of the hand before ascending the lateral aspect of the upper limb.
• At the level of the shoulder it courses along the delto-pectoral groove, between the lateral border of the pectoralis major and medial aspect of the deltoid. This is the point of access for endovascular leads (Figure 58-1A).
FIGURE 58-1A Anatomy of the venous drainage of the upper limb relevant to endovascular lead implant.
• From the deltopectoral groove, the cephalic vein descends deeply, piercing the clavipectoral fascia, to join the axillary vein (itself a continuation of the basilic vein from the same dorsal arch of the hand). This is illustrated in Figure 58-1B.
FIGURE 58-1B Digital subtraction contrast venogram demonstrating the radiographic anatomy of the cephalic, axillary, and subclavian veins. Note the pacemaker anterior to the axillary vein. The leads were implanted via the subclavian vein, which remains patent.
• The axillary vein ends at the lateral border of the first rib, where it becomes the subclavian vein (see Figure 58-1A).
• A medial site of entry into the subclavian vein risks passage through the costoclavicular ligament and/or the subclavius muscle, with subsequent “subclavian crush” leading to conductor fracture.8
• The relative courses of leads implanted via cephalic and axillary approaches are shown in Figure 58-2.
FIGURE 58-2 Postero-anterior chest x-ray demonstrating the radiographic correlates of cephalic and subclavian vein implant routes. The ventricular lead of this dual chamber pacemaker was implanted through the cephalic vein and advanced to the RV septum. This was not of sufficient caliber to accept two leads (which occurs uncommonly), so the atrial lead was implanted through the extrathoracic subclavian vein. Note the different initial angles of approach (marked by the arrowed anchoring sleeves); then both leads converge on the subclavian vein.
CEPHALIC VEIN CUT DOWN TECHNIQUE
In our practice, three routes for permanent endovascular lead implantation are used: extrathoracic subclavian vein puncture, cephalic vein cut down, and iliac vein puncture.
Cephalic vein cut down is performed as follows:
• The incision is made to expose the superior part of the delto-pectoral groove (Figure 58-3A). This may be accomplished by a horizontal incision parallel and inferior to the clavicle, with its lateral margin overlying the deltopectoral groove. In some cases this may be displaced laterally relative to a conventional approach for subclavian access. The alternative approach, favored by our group, is to make a diagonal incision along the deltopectoral groove itself, extending superiorly to terminate approximately 1 cm below the inferior margin of the clavicle. The groove is easily visualized in thin or muscular patients. In obese patients, it is best palpated.
FIGURE 58-3A Following formation of the subcutaneous pocket and minor dissection of soft tissues, the cephalic vein is exposed in the delto-pectoral groove. In this series of intraoperative photographs, medial is at the top, and cephalad at right.
• Typically, we create a pocket first, since this provides more mobility in the space and permits assessment of hemostasis during the procedure. A conventional subcutaneous pocket may be formed, or submuscular if desired. The deltopectoral groove from this position is usually marked by a line of adipose tissue between pectoralis and deltoid, covered by a light condensation of fascia. These connective tissues are separated using blunt dissection to expose the cephalic vein in the groove.
• Further blunt dissection is performed to remove adherent connective tissues and thus mobilize several centimeters of the vein. It is important to expose the proximal aspect of the vein before it passes below the clavicle since this portion may deviate in direction or lead to branch vessels which may need to be tied off.
• The vein is controlled with two silk half-ties with long tails: one distally and one proximally (Figure 58-3C). These are passed below the vessel, which may be lifted with Gemini forceps (useful when the vein passes deep in the groove or in cases of marked obesity). The distal end is tied off at this stage, but this may be deferred until access is achieved in cases where patients are hypovolemic or the vein is collapsed or small.
FIGURE 58-3C The vein is controlled proximally and distally with two silk half-ties. Tension applied to the proximal (cephalad) tie secures hemostasis yet permits passage of lead or sheath or guidewire. This is useful when venous pressures are high.
• A small venotomy (about one-third of the circumference of the vein) is then performed on the anterior surface of the vein with an iris or Potts scissors. Alternatively, the vein can be cannulated with a needle.
• The venotomy is held open with a vein pick (Figure 58-3D).
• A lead (or a lead and guidewire in the case of dual chamber devices) is inserted directly into the vein (Figure 58-3E). The lead is advanced and positioned in the desired cardiac chamber in the usual fashion. Peel-away sheaths can also be advanced over guidewires, usually with surprising ease since the cephalic vein is remarkably distensible.
FIGURE 58-3D After a venotomy is made on the anterior surface of the vein, a vein pick can be used to hold the venotomy open while a guidewire is advanced. The pick can then be removed.
• The proximal half-tie achieves hemostasis. Initially, slight tension may be applied as a temporary measure while leads are manipulated. For permanent hemostasis, it is tied over the anchoring sleeve once the lead(s) have been delivered. If possible, the tip of the anchoring sleeve is advanced partially into the venotomy. The suture is tied with enough tension to secure vein to lead and achieve hemostasis, avoiding excessive force, which may damage underlying lead insulation.
• The anchoring sleeve is secured medially to the pectoralis muscle with nonabsorbable ties (Figure 58-3F).
FIGURE 58-3F The anchoring sleeve is tied to pectoralis major.
• Occasionally, a 5 Fr dilator and/or a hydrophilic wire is useful to direct and advance a guidewire through the cephalic vein in cases where it is narrow or tortuous. When encountered, this is typically at the point where the vessel pierces the clavipectoral fascia to join the axillary vein.
• Contrast venography can also be performed through this dilator to define the anatomy or diagnose a dissection if difficulty is encountered.
• Blunt dissection around and mobilization of the proximal part of the vein where it courses deeply toward the axillary vein facilitates passage of leads in many cases, and we perform this routinely. This also permits delivery of a purse-string (absorbable #0) suture below the vessel to draw pectoralis and deltoid together to secure hemostasis. This may be necessary when right sided filling pressures are elevated.
• Anchoring sleeves should be tied down to the pectoralis major. Wound closure remains unchanged to conventional. The deltopectoral area, following dissection and lead delivery, requires no additional closure after securing hemostasis.
• For CRT, a useful approach is to access the cephalic with a guidewire, and use this as a target to perform a single extrathoracic subclavian vein puncture for the left ventricular lead, which may be easier to implant from this route. The right ventricular and atrial leads are then implanted via the cephalic vein.
• When direct subclavian access is required, we prefer puncture over the lateral part of the first rib under fluoroscopic guidance. If the needle is not advanced past the first rib, pneumothorax is extremely unlikely. We also prefer to pass the needle directly to the vein at an angle dictated by the individual patient anatomy. While some have advocated a horizontal course until the needle tip is over the first rib, with subsequent tilting downward of the tip to advance to the vein, this results in an acutely angled track through the muscle, which may cause additional stress on the lead.
• Upgrading systems already implanted via the axillary or subclavian approach may be performed using the cephalic vein. The lead may be added with the approach described.
• Occasionally, the deltoid branch of the thoraco-acromial artery may course through the deltopectoral groove. Although inadvertent lead delivery is not possible in such a small vessel, laceration has to be carefully avoided. If this arterial branch shares connective tissues common with the cephalic vein, freeing the two structures from each other with blunt dissection is important.
FIGURE 58-3B The vein is mobilized with blunt dissection.
FIGURE 58-3E When implanting a dual-chamber system, a lead can usually be directly inserted beside the guidewire. If not, then a peel-away sheath can be passed over the guidewire and lead inserted conventionally.
• The cephalic vein is prone to displaying variations. If not visualized immediately, it may be found beneath the lateral border of pectoralis major. When branching, the medial branch vessel should be targeted for passage of lead/guidewire. Sometimes, the cephalic vein terminates within the deltopectoral groove in a mesh of small vessels, which may preclude passage of a wire. Rarely, the vein courses over the clavicle. Although this gains entry ultimately into the subclavian vein, this route should be avoided since a lead is heavily angled when taking this course and is vulnerable to trauma over the clavicle.
• Despite experience, cephalic vein access is not always possible. In our experience of 54 attempts over 1 year, access was successful in 45 (83.3%), consistent with another large experience.9 Failure was due to:
Cephalic vein not visualized: 3 (5.5%)
Atretic: 3 (5.5%)
Aberrant course: 1 (1.9%)
Existing leads: 1 (1.9%)
Dissection: 1 (1.9%)
• With the use of additional guidewires and other techniques, success rates can be further extended; however, the operator has to balance this with prolonged procedure times.10,11 Typically, in our practice, if the vein is not accessed within 5 minutes of incision time, we revert to the extrathoracic subclavian approach. However, when the relationship of bony landmarks is distorted with kyphosis (especially in elderly females), the accuracy of fluoroscopically guided sticks is reduced, and risks, such as pneumothorax, are increased. This may have severe consequences in some patients, for example, those with severe emphysema. Under these conditions, cephalic approach is preferred.
• Follow-up of leads implanted via the cephalic vein is identical to that for extrathoracic subclavian leads.
• Although ipsilateral pneumothorax is virtually impossible, postimplant postero-anterior and lateral chest X-ray is recommended to document lead position and assess for other complications.
• The risk of ipsilateral venous thrombosis is not affected by cephalic or subclavian access.12,13
• Data on the impact of venous access on lead survival are conflicting, and it may be difficult to distinguish any effect of cephalic vein access from the known increased risk of lead fracture with suboptimal subclavian puncture technique.
• Nonetheless, cephalic access was associated with improved survival in two recently recalled ICD lead models.6,7
• The approach does not alter technique or success rate of subsequent transvenous lead extraction if this is necessary.
1. Byrd CL. Clinical experience with the extrathoracic introducer insertion technique. Pacing and Clin Electrophysiol. 1993:16(9);1781-1784.
2. Parsonnet V, Zucker R, Gilbert L, Myers GH. Clinical use of an implantable standby pacemaker. JAMA. 1966:196(9);784-786.
3. Parsonnet V, Roelke M. The cephalic vein cutdown versus subclavian puncture for pacemaker/ICD lead implantation. Pacing and Clin Electrophysiol. 1999;22(5):695-697.
4. Calkins H, Ramza BM, Brinker J, 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. J Cardiovasc Electrophysiol. 2001;24(4 Pt 1):456-464.
5. Jacobs DM, Fink AS, Miller RP, et al. Anatomical and morphological evaluation of pacemaker lead compression. Pacing Clin Electrophysiol. 1993;16(3 Pt 1):434-44.
6. Erkapic D, Duray GZ, Bauernfeind T, Rosa SD, Hohnloser SH. Insulation defects of thin high-voltage ICD leads: an underestimated problem? J Cardiovasc Electrophysiol. 2011;22(9):1018-1022.
7. Birnie DH, Parkash R, Exner DV, et al. Clinical predictors of Fidelis lead failure: report from the Canadian Heart Rhythm Society Device Committee. Circulation. 2012;125(10):1217-1225.
8. Magney JE, Flynn DM, Parsons JA, et al. Anatomical mechanisms explaining damage to pacemaker leads, defibrillator leads, and failure of central venous catheters adjacent to the sternoclavicular joint.Pacing Clin Electrophysiol. 1993;16(3 Pt 1): 445-57.
9. Tse HF, Lau CP, Leung SK. A cephalic vein cutdown and venography technique to facilitate pacemaker and defibrillator lead implantation. Pacing Clin Electrophysiol. 2001;24(4 Pt 1): 469-473.
10. Neri R, Cesario AS, Baragli D, et al. Permanent pacing lead insertion through the cephalic vein using a hydrophilic guidewire. Pacing Clin Electrophysiol. 2003:26(12);2313-2314.
11. Kolettis TM, Lysitsas DN, Apostolidis D, Baltogiannis GG, Sourla E, Michalis LK. Improved “cut-down” technique for transvenous pacemaker lead implantation. Europace. 2010:12(9);1282-1285.
12. Rozmus G, Daubert JP, Huang DT, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. J Interv Card Electrophysiol. 2005;13(1):9-19.
13. Haghjoo M, Nikoo MH, Fazelifar AF, Alizadeh A, Emkanjoo Z, Sadr-Ameli MA. Predictors of venous obstruction following pacemaker or implantable cardioverter-defibrillator implantation: a contrast venographic study on 100 patients admitted for generator change, lead revision, or device upgrade. Europace. 2007;9(5);328-332.