A simple method of axillary venipuncture using single landmark for pacemaker leads implantation

BACKGROUND

Axillary venipuncture for pacemaker lead implantation has been demonstrated to be an effective method without fatal complications encountered with standard subclavian access approach, but the relatively high complexity limits its clinical practicability.

OBJECTIVE

We are proposing a simple technique for axillary venipuncture using single point on clavicle as anatomical landmark with the possibility of alternative fluoroscopic assisted puncture as a backup.

METHODS

Connecting point of medial to middle third of clavicle is located as the landmark. Deflected lateral 45°from sagittal line, an 18-guage needle tip is laid on the point and tangential to upper border of clavicle. Penetrated from the hub site, the needle is directed to the landmark at approximately 30-45° relative to body surface for venipuncture. If blind puncture failed, an alternative fluoroscopic method is performed. Upon successful venipuncture, a guide wire is positioned in inferior vena cava and a skin incision and subcutaneous pocket is made at the puncture site.

RESULTS

Axillary vein puncture was successful for 106 of 113 patients (93.8%) in the study with mean access time of 3.6 ± 1.4 min. In 84 patients (74.3%), the vein was cannulated by blind puncture, and fluoroscopy guided method was required in other 22 patients (19.5%). The puncture of axillary artery occurred in one patient (0.09%) and no haemorrhage was observed after local pressure. No pneumothorax, hemothorax, or brachial plexus injury was found.

CONCLUSIONS

The approach of axillary vein puncture using single landmark on the clavicle is simple, effective and safe for pacemaker lead implantation.

External iliac vein dimensions may change after placement of a more proximal iliac vein stent

OBJECTIVE

We have occasionally observed during vein stenting for proximal iliac vein stenosis, the appearance of a more distal stenosis in the iliac vein that had not been initially observed before placement of the more proximal vein stent. In the present retrospective study, we aimed to document this observation.

METHODS

We identified patients in whom changes in the area measurement and linear dimensions of the external iliac vein (EIV) were observed on venography and/or intravascular ultrasound (IVUS) after stent placement for chronic nonthrombotic iliac stenosis in the common iliac vein (CIV). The images of these IVUS scans were subsequently analyzed to determine the cross-sectional area, major axis, and minor axis measurements in the EIV, before and after placement of a proximal CIV stent.

RESULTS

A total of 32 limbs with complete and quality IVUS and venography images available that allowed for measurement of the EIV before and after vein stent placement in the CIV were evaluated. The patient cohort was 55% men, with a mean age of 63.8 ± 9.9 years and a mean body mass index of 27.8 ± 7.8 kg/m². Of the 32 limbs, 18 were left sided and 14 were right sided. Most (n = 12 [60%]) of the limbs had presented with venous-related skin changes (C4 disease). The remainder of the cohort had had active (C6 disease; n = 4 [20%]) or recently healed (C5 disease; n = 1 [5%]) venous ulceration and isolated venous-related edema (C3; n = 3 [15%]). The minimal CIV area before and after CIV stenting was 28.47 ± 23.53 mm² and 196.34 ± 42.62 mm², respectively. The minimal mean EIV cross-sectional area before and after CIV stenting was 87.44 ± 38.55 mm² and 50.69 ± 24.32 mm², respectively, a statistically significant reduction of 36.75 mm² (P < .001). The mean EIV major axis and minor axis had both decreased similarly. The minimal mean EIV major axis before and after CIV stenting was 15.22 ± 3.13 mm and 11.13 ± 3.58 mm, respectively (P < .001). The minimal mean EIV minor axis before and after CIV stenting was 7.26 ± 2.40 mm and 5.84 ± 1.42 mm, respectively (P < .001).

CONCLUSIONS

The results from the present study have shown that the dimensions of the EIV can change significantly after placement of a proximal CIV stent. Possible explanations include masked stenosis due to distal venous distention resulting from the more proximal stenosis, vascular spasm, and anisotropy. The presence of proximal CIV stenosis can potentially lessen the appearance, or completely mask the presence, of an EIV stenosis. This phenomenon appears unique to venous stenting, and the prevalence is unknown. These findings underscore the importance of completion IVUS and venography after venous stent placement.

A Case Report of Brachiocephalic Vein Spasm Secondary to Peripherally Inserted Central Catheter

Vascular spasm is well known and studied in the arterial system. There are only a few cases reported related to central venous spasms. We present the case of a 63-year-old male with an extensive medical history, including deep vein thrombosis (DVT), who underwent peripheral insertion of a central catheter in his left upper extremity with subsequent development of left upper extremity edema. The central catheter was removed before the patient underwent a contrast-enhanced computed tomography of the chest which revealed severe narrowing of the left brachiocephalic vein, consistent with venospasm in the clinical setting. Nitroglycerin might be useful to prevent vasospasm, or it might also be used for treatment. In our case, the catheter was removed, and no subsequent treatment was necessary.

Refractory axillary venous spasm during permanent pacemaker implantation

Background

Vascular spasm is well known to occur in the arterial system. Central venous spasm during pacemaker implantation is uncommon with only a few cases reported from time to time. Sometimes, the venous spasms may not respond to nitroglycerine injections which requires a change of access site and undue discomfort for the patient.

Case presentation

A 72-year-old female patient with no prior comorbidities presented to us with recurrent dizziness on exertion and at rest. The electrocardiogram showed complete heart block, likely to be of sclerodegenerative etiology as the patient did not have any ischemic symptoms, also the electrocardiogram and echocardiogram did not show any evidence of ischemia. As part of the hospital protocol, a venogram was performed by giving intravenous diluted contrast (iohexol) through the left brachial vein, which showed good-sized axillary and subclavian veins. We attempted to cannulate the left axillary vein with a 16G needle using Seldinger technique, but the axillary vein could not be cannulated despite multiple attempts. We gave incremental boluses of intravenous nitroglycerine, despite that the left axillary vein could not be cannulated. Repeat intravenous contrast injection showed severe spasm of axillary and subclavian veins. Finally, the axillary vein was cannulated from the right side using anatomical landmarks and a pacemaker was implanted.

Conclusions

Venous spasm during device implantation although uncommon, it should be anticipated in patients with difficult cannulation to prevent inadvertent complications like pneumothorax and arterial injuries. Mild venous spasm may relieve with time but severe venous spasm may require a change of access site

An unyielding valve leading to venous spasm during pacemaker implantation: a case report

BACKGROUND

Subclavian venous spasm is an uncommon complication during permanent pacemaker implantation. The exact aetiology of subclavian venous spasm is not clear but has been suggested to be due to either mechanical irritation of the vein during needle puncture or due to chemical irritation from contrast injection. Here, we report a case of an unyielding subclavian vein valve that impeded guidewire advancement and the repeated guidewire manipulation led to venous spasm.

CASE SUMMARY

A 45-year-old woman with a history of surgical repair of Tetrology of Fallot in childhood presented with symptomatic bifascicular block and underwent a permanent pacemaker implantation. A subclavian venogram done prior to the procedure showed a prominent valve in the distal portion of the vein. Following venous puncture, guidewire advancement was impeded by the prominent valve. The resulting guidewire manipulation led to subclavian venous spasm necessitating a medial subclavian venous puncture and access.

DISCUSSION

Prolonged mechanical irritation of the vein during pacemaker implantation may lead to venous spasm impeding pacemaker implantation. Early identification of an impeding valve and obtaining access medial to the valve may help prevent this uncommon complication.

Coronary sinus catheter placement via left cubital vein for phrenic nerve stimulation during pulmonary vein isolation

Phrenic nerve (PN) stimulation is essential for the elimination of PN palsy during balloon-based pulmonary vein isolation (PVI). Although ultrasound-guided vascular access is safe, insertion of a PN stimulation catheter via central venous access carries a potential risk of the development of mechanical complications. We evaluated the safety of a left cubital vein approach for positioning a 20-electrode atrial cardioversion (BeeAT) catheter in the coronary sinus (CS), and the feasibility of right PN pacing from the superior vena cava (SVC) using proximal electrodes of the BeeAT catheter. In total, 106 consecutive patients who underwent balloon-based PVI with a left cubital vein approach for BeeAT catheter positioning were retrospectively assessed. The left cubital approach was successful in 105 patients (99.1%), and catheter insertion into the CS was possible for 104 patients (99.0%). Among these patients, constant right PN pacing from the SVC was obtained for 89 patients (89/104, 85.6%). In five patients, transient loss of right PN capture occurred during right pulmonary vein ablation. No persistent right PN palsy was observed. Small subcutaneous hemorrhage was observed in eight patients (7.5%). Neuropathy, pseudoaneurysm, arteriovenous fistula, and perforations associated with the left cubital approach were not detected. Body mass index was significantly higher in the right PN pacing failure group than in the right PN pacing success group (26.2 ± 3.2 vs. 23.8 ± 3.8; P = 0.025). CS catheter placement with a left cubital vein approach for right PN stimulation was found to be safe and feasible. Right PN pacing from the SVC using a BeeAT catheter was successfully achieved in the majority of the patients. This approach may prove to be preferable for non-obese patients.