Edmond M. Cronin, MD MB BCh BAO, Niraj Varma, MA, DM, FRCP, Bruce L. Wilkoff, MD
A 45-year-old woman presents for reimplantation of a pacemaker. She has a history of congenital aortic stenosis and mitral valve prolapse and has had four open-heart surgeries, including mechanical aortic and mitral valve replacements. A dual-chamber pacemaker was implanted from the left due to postoperative complete heart block. The ventricular lead subsequently fractured, and as the left subclavian vein was found to be occluded, the system was abandoned, and a new pacemaker system was implanted via the right subclavian. She developed swelling of her pacemaker pocket, fever, and blood cultures positive for Staphylococcus aureus without vegetations identified by TEE. The active pacing system and the leads from both subclavian access sites were extracted percutaneously without complications. The patient retains a good atrial rhythm but has complete heart block without any ventricular escape rhythm and is supported by a temporary pacing electrode. As neither subclavian region is sterile, available transvenous routes are limited to the iliac vein.
• The rise in cardiac implantable electronic device (CIED) implants over the past decade has been accompanied by an increasing number of patients with CIED-related infections and challenging lead management situations (Figure 59-1).
FIGURE 59-1 Multiple bilateral abandoned leads with contrast venogram demonstrating occlusion of the left subclavian vein. In this patient, a total of four leads have been implanted via the left subclavian vein, and two via the right subclavian vein. In this situation, if lead-related endocarditis occurs, all hardware must be extracted, and reimplant options are largely limited to the iliac or epicardial routes.
• Traditionally, leads have been implanted via the subclavian vein, which is accessed using either subclavian or axillary vein puncture or cephalic vein cut down.
• When there is obstruction to access through both subclavian veins or the superior vena cava, or when infected leads have recently been extracted from these veins, reimplantation is either precluded or inadvisable using these routes.
• Epicardial lead placement is often possible and may be the best choice if there are ongoing intracardiac vegetations or other concurrent indications for cardiac surgery. Nevertheless, it demands a more invasive procedure, is historically associated with inferior lead survival, and is often accompanied by higher capture thresholds.1
• A variety of alternative intracardiac approaches have been described, including a minithoracotomy with transatrial implant2; and transvenous access via the inferior vena cava, hepatic vein, femoral vein, and iliac vein.3,4
• The iliac vein approach (often mistakenly named “femoral vein” in the original description3 and others) is the most widely accepted transvenous alternative to superior vein access and is particularly useful after extraction for infection.5
• Direct entry to the iliac vein is preferred since this approach avoids flexion of the lead as it crosses the inguinal ligament, which occurs with a true femoral vein approach (though this can also be performed).
• The femoral vein ascends the thigh, accompanying the femoral artery, receiving several tributaries before reaching the level of the inguinal ligament.
• The inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle.
• The femoral vein becomes the external iliac vein as it passes deep to the inguinal ligament into the abdomen; this is the site of venous access when using the iliac vein technique.
• The external iliac joins the internal iliac to become the common iliac vein; this joins with the contralateral common iliac to become the inferior vena cava.
ILIAC VEIN IMPLANT TECHNIQUE
• The right external iliac vein is most commonly used as this provides a more direct route to the heart, although both are suitable.
• The femoral vein is cannulated using the modified Seldinger technique, and a short 0.035 inch guidewire is introduced as a landmark and the external end secured to the drape using a mosquito or Kelly clamp.
• The inguinal ligament is identified by direct palpation using the bony landmarks described previously.
• A 2-cm incision is made just cephalad to the inguinal ligament, medial to the femoral arterial pulse.
• The incision is carried down to the fascia covering the external oblique.
• The external iliac vein is then cannulated using a direct stick from the fascia under fluoroscopic guidance using the guidewire as a target (Figure 59-2). It is important to keep the needle and attached syringe vertical to avoid puncturing too cephalad, which risks entering the peritoneal cavity, or too caudal, which would enter the femoral vein and produce a tight kink in the lead. This necessitates the operator’s hand being briefly in the X-ray field of view.
FIGURE 59-2 Puncture of the external iliac vein under fluoroscopic guidance, using a guidewire in the vein (introduced from the femoral vein caudal to the access site; arrow) as a target. Note the vertical orientation of the needle with a syringe attached (arrowhead), in the operator’s hand. The site of puncture is just above the pelvic brim.
• As with other transvenous routes of access, it is our practice to puncture the vein separately for each lead, to avoid lead-lead interaction, which can be experienced with the retained guidewire technique. However, this technique may also be used if it is the operator’s preference.
• A long (24-cm) straight peel-away sheath is advanced over the guidewire (such as SafeSheath Long, Pressure Products, San Pedro, CA).
• Long, 75 to 100 cm, active fixation pace/sense or defibrillator leads are used.
• Active fixation leads are preferred as the risk of lead dislodgment is potentially higher with the iliac approach.4
• Atrial lead positioning is straightforward. The lead is advanced to the right atrial appendage or lateral wall, and the helix is deployed.
• Ventricular lead positioning is more complex. The stylet can be fashioned with a 90-degree angle approximately 5 cm from the tip to enable direct advancement to the right ventricular apex. Alternatively, an alpha loop can be created in the atrium, analogous to the technique used in cases of persistent left superior vena cava, and the lead advanced to the ventricle (Figure 59-3). With either technique, care should be taken to confirm that the lead is in the right ventricle and not in the coronary venous system. This necessitates fluoroscopy in both oblique projections.
FIGURE 59-3 Postero-anterior (A) and left lateral (B) X-rays of a single-chamber ICD attached to a single-pass dual coil ICD lead implanted using the iliac vein technique, and utilizing an alpha loop in the right atrium to position the SVC coil in the heart. Note that slack must account for abdominal girth.
• Coronary venous lead placement for cardiac resynchronization therapy has also been described from the iliac vein route.6 Preshaped catheters can be used to engage the coronary sinus and perform venography, and a long peel-away sheath is used to deliver the lead using standard techniques. Both passive6 and active fixation7 coronary venous leads have been used, although the latter may present additional difficulty if subsequent lead extraction is required.8
• A generous degree of slack is necessary to account for abdominal and diaphragmatic excursions acting to draw the leads away from the heart.
• The leads and suture sleeves are reflected cephalad onto the abdominal fascia and are tied down to the muscle over the suture sleeves with nonabsorbable suture in the same fashion as with the superior approach. A purse-string or figure-of-eight suture may be used around the leads for hemostasis.
• The pocket is then fashioned. In our practice, it is created in the upper abdomen, on the ipsilateral side to venous access for pacemakers and on the left for implantable cardioverter defibrillators (ICDs). This facilitates defibrillation efficacy and allows for a placement of left posterior chest subcutaneous coil if defibrillation is not effective. A lower quadrant position for pacemaker implantation, utilizing a single incision, is also described.9
• The lead is then tunnelled from the access site to the pocket, using either a tunnelling tool or a Penrose drain (Figure 59-4).
FIGURE 59-4 Tunneling of the lead. After the lead is secured to the fascia, it is tunneled to the pocket fashioned in the ipsilateral upper abdominal quadrant using a tunneling tool or a Penrose drain.
• After irrigation (and defibrillation efficacy testing in the case of ICDs), the incisions are closed, and the final appearance is documented fluoroscopically (Figure 59-5).
FIGURE 59-5 Fluoroscopic appearance of a single-lead pacemaker with the lead implanted using the iliac vein technique.
SPECIAL CONSIDERATIONS FOR ICDs
• The iliac approach produces an altered vector from that seen with pectoral implants, as the can is in the upper abdomen, in the same position as was used for earlier, larger transvenous defibrillators.
• For single chamber ICDs, a single dual coil defibrillator lead with an alpha loop in the right atrium permits a good defibrillation vector with the SVC coil in the heart (Figure 59-3).
• For dual-chamber systems, two single coil defibrillator leads with one in the right ventricle and one in the right atrium permits the RA lead DF-1 pin to be used as the SVC port coil and the RV lead DF-1 pin as the RV port coil (Figure 59-6). This minimizes the amount of redundant lead length and the chances of lead-lead interactions.
FIGURE 59-6 Dual-coil system using two ICD leads, each a single-coil lead. The ventricular electrode is deployed and connected conventionally. The defibrillation coil of the atrial lead is connected to the SVC port of the defibrillator, while the IS-1 component of the same lead is connected conventionally to the atrial port for pacing and sensing in the atrium.
• Defibrillation threshold is higher with abdominal compared with pectoral implant sites, and addition of a subcutaneous coil has been necessary to achieve an adequate safety margin in one-third of patients.10Defibrillation efficacy testing is required with this approach.
Follow-up is identical to that for devices placed via a superior venous approach. A high rate of lead dislodgement, especially atrial, has been described by some authors,3,4,11 although not by others,12 and is rare in our experience5,10of 115 iliac implants over 15 years. Routine use of active fixation leads, testing for current of injury by unfiltered electrograms recording,13 and addition of adequate slack may all be contributors to a low rate of lead dislodgement. Nevertheless, maintaining a high degree of vigilance during follow-up is necessary. This may be aided by using generators with remote monitoring capability.14There is no evidence of an increased rate of venous thrombosis, phlebitis, or pocket infection following iliac vein implantation,3-5,9-12 though the number of published cases is small. Deep venous thrombosis has not been a problem with iliac vein implantation, and patients return to full, active lifestyles.
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8. Cronin EM, Ingelmo CP, Rickard J, et al. Active fixation mechanism complicates coronary sinus lead extraction and limits subsequent reimplantation targets. J Interv Card Electrophysiol. 2013;36(1):81-86.
9. Barakat K, Hill J, Kelly P. Permanent transfemoral pacemaker implantation is the technique of choice for patients in whom the superior vena cava is inaccessible. Pacing Clin Electrophysiol. 2000;23(4 Pt 1):446-449.
10. Ching CK, Elayi CS, Di Biase L, et al. Transiliac ICD implantation: defibrillation vector flexibility produces consistent success. Heart Rhythm. 2009;6(7):978-983.
11. Mathur G, Stables RH, Heaven D, Ingram A, Sutton R. Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach. Europace. 2001;3(1):56-59.
12. García Guerrero JJ, De La Concha Castañeda JF, Fernández Mora G, et al. Permanent transfemoral pacemaker: a single-center series performed with an easier and safer surgical technique. Pacing Clin Electrophysiol. 2005;28(7):675-679.
13. Saxonhouse SJ, Conti JB, Curtis AB. Current of injury predicts adequate active lead fixation in permanent pacemaker/defibrillation leads. J Am Coll Cardiol. 2005;45(3):412-417.
14. Varma N, Michalski J, Epstein AE, Schweikert R. Automatic remote monitoring of implantable cardioverter-defibrillator lead and generator performance: the Lumos-T Safely RedUceS RouTine Office Device Follow-Up (TRUST) trial. Circ Arrhythm Electrophysiol. 2010;3(5):428-436.