Infraclavicular lead failure: tarnish on a golden route

Extrathoracic subclavian-axillary vein location and morphological features over the first rib for pacemaker and defibrillator lead implantation

BACKGROUND

We aimed to describe the variations of extrathoracic subclavian-axillary vein location and its morphology over the first rib by venography in order to facilitate venous puncture using fluoroscopic landmarks without contrast venography, and evaluate the success rate of punctures, which is made with our method.

METHODS

Patients who had undergone de novo lead implantation with the help of prepuncture venography between 2011 and 2015 were enrolled. For detection of the segmental location of the axillary vein, the zones were defined (Zone 1: Posterior, Zone 2: Lateral, Zone 3: Medial) at the first rib by fluoroscopy. Additionally, patients, who underwent venous puncture with our method after January 2017, were evaluated in terms of puncture success.

RESULTS

Four hundred thirty-three patients who had prepuncture contrast venography for defibrillator or pacemaker lead implantation in 2011-2015 were analyzed. The most common position of the axillary vein was found to be over zone 2 (91%) while the zone 1 location was 8.5% and the zone 3 was 0.5%. Venous valves were detected on the first rib in 98 patients. After January 2017, venous puncture using fluoroscopic landmarks was performed to 171 patients. The punctures were successfully performed over zone 2 with our method in 90.7% of the patients.

CONCLUSIONS

The most common radioanatomic position of the extrathoracic subclavian-axillary vein was observed at zone 2 according to our method and the probability of presence of venous valve over the first rib is 22%. Additionally, the success rate of puncture using fluoroscopic landmarks over zone 2 was 90.7%.

Use of Cryopreserved Small Aortic Homografts for Large Vein Replacement

Total obstruction, stenosis, or ligation of any large vein is associated with significant morbidity. No synthetic grafts can adequately replace large veins, particularly in areas subjected to motion (flexion or extension). Artificial prosthetic materials usually occlude within a short period.

Since 1987, the author has used cryopreserved allografts of small aortas varying from 1 to 1.7 cm in diameter to replace large vein channels in the upper or lower body. These allografts provide a manageable, pliable conduit with normal endothelium. He implanted grafts bridging gaps from 4 to 30 cm in length, in 14 patients (10 women, 4 men). Veins replaced were five iliac, three iliofemoral, and six subclavian-innominate. The long-term patency rate (follow-up 3 months to 10 years) is 93%.

The use of small aortic cryopreserved homografts for large vein replacement, particularly in mobile areas (groin, thoracic inlet, pelvis) is recommended. These grafts appear superior to any previous grafts used for the same purpose.

Radiology of cardiac devices and their complications

This article familiarizes the reader with several different cardiac devices including pacemakers and implantable cardioverter defibrillators, intra-aortic balloon pumps, ventricular assist devices, valve replacements and repairs, shunt-occluding devices and passive constraint devices. Many cardiac devices are routinely encountered in clinical practice. Other devices are in the early stages of development, but circumstances suggest that they too will become commonly found. The radiologist must be familiar with these devices and their complications.

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.

Durability of Repaired Sensing Leads Equivalent to that of New Leads in Implantable Cardioverter Defibrillator Patients with Sensing Abnormalities

Breaks in the insulation portions of implantable cardioverter defibrillator (ICD) leads may cause nonphysiological sensing and subsequent inappropriate ICD therapy, and may also interfere with the sensing and pacing functions of the ICD. Previously, leads with insulation breaks have been replaced with new sensing leads. However, repair of leads, utilizing a commercially available patch kit may reduce the morbidity, hospital stay, and cost of lead replacement. The long-term durability of these repairs has not previously been reported and is the subject of this study. Patients undergoing ICD sensing lead repair or replacement constituted the study population. Patients were followed at 3 month intervals with an endpoint of new lead abnormalities necessitating repeat lead repair or replacement. Twenty-five patients underwent lead repair and 27 individuals underwent lead replacement for either preoperative nonphysiological sensing (n = 25) or intraoperative evidence of insulation break (n = 27). There was no significant difference between the individuals undergoing lead repair or replacement in age (59 +/- 9 vs 60 +/- 12 years), mean left ventricular ejection fraction (40%+/- 18% vs 33%+/- 17%) or age of the lead being repaired or replaced (4.5 +/- 2.0 years vs 5.0 +/- 2.0 years). During follow-up of 44 +/- 23 months, 4 of the repaired leads and 4 of the replaced leads developed new insulation breaks requiring surgical intervention (P = 0.43). In conclusion, in nearly 4 years of follow-up of patients with sensing lead insulation breaks, there was no difference is subsequent lead survival in those with lead repair compared to those with new sensing leads inserted. The strategy of lead repair, when technically feasible, should thus be considered in all patients with sensing abnormalities secondary to insulation breaks.

Blind axillar venous access

The axillary vein has been suggested as an alternate site for venous access to avoid the "subclavian crush phenomenon. " Many techniques have been used to access this structure. They include complicated anatomical landmarks, contrast venography, Doppler, and ultrasound. A simple technique using the basic anatomical landmark of the deltopectoral groove and a blind venous stick has been used successfully in 165 of 168 consecutive pacemaker and ICD procedures; there were only three failures. These required an alternate approach. With a thorough knowledge of the regional anatomy, the axillary vein can be safely used as a primary site of venous access.

Blind extrathoracic subclavian venipuncture for pacemaker implant: a 3-year experience in 250 patients

We report our 3-year experience using a modification of the percutaneous technique for extrathoracic subclavian venipuncture proposed by Magney and colleagues for permanent pacing lead placement. Before surgery bony landmarks were marked on the skin according to Magney's description to identify the needle entry point and the target point corresponding to the ideal location of the extrathoracic portion of the subclavian vein. Then the venipuncture was accomplished by inserting the needle through a standard infraclavicular pacemaker pocket. Two hundred fifty patients undergoing primary pacemaker implant (231 patients) or reimplant or change of mode of pacing (19 patients) were included in the study. The technique was successful in 245 (98%) cases. Inadvertent puncture of the subclavian artery occurred in 5 (2%) patients but in no case did it jeopardize the success of the implant procedure. No major complications were observed. Seven (2.9%) patients experienced early complications unrelated to the venous approach: 2 subclavian vein thrombosis, 5 lead dislodgment in 4 patients, and 1 pocket hematoma. During a mean follow-up of 15.2 months (range 4-40) no lead or patient related complications occurred. In the present study the blind approach to the extrathoracic portion of the subclavian vein proved to be safe and effective for pacing lead insertion. Further observations are required to establish whether this method extends the lead survival.

Insulation lead failure: is it a matter of insulation coating, venous approach, or both?

Lead insulation material and implant route have a major impact on lead reliability and durability. We compare the incidence of lead insulation failure resulting from both the venous approach and insulation type. Two hundred ninety consecutive leads were followed for a mean period of 57 +/- 30 months; leads with < 1 year follow-up were excluded. There were 116 Silicone Rubber insulated leads and 174 with polyurethane (151 Pellethane 80A and 23 Pellethane 55D) insulation; 279 leads were bipolar and 11 unipolar; 274 leads were implanted in the ventricle and 66 in the atrium. The venous route was the subclavian vein for 170 leads (58%) and the cephalic vein for 120 leads (42%). Insulation failure was diagnosed when a single sign of oversensing, undersensing, failure to capture, early pulse battery depletion, and lead impedance < 250 omega was present. Measurement of lead impedance was performed intraoperatively at implantation and during lead revision or pulse generator replacement. Lead failure caused by conductor coil fracture was not considered. There were 13 lead insulation failures, all among leads with polyurethane insulation (12 Pellethane 80A and 1 Pellethane 55D). Eleven failures (10%) occurred when the subclavian vein and 2 (3%) when the cephalic vein approach was used. The cumulative survival rate of polyurethane and silicone rubber insulated leads was 88.7% and 100%, respectively (P = 0.02); the cumulative survival rate of polyurethane insulated leads was 83.2% when the subclavian vein and 95.1% when the cephalic vein were used (P = 0.03). The mean time to polyurethane lead failure when the subclavian vein approach was used was 54 +/- 17 months and when the cephalic route was 73 +/- 4 months (P < 0.02). By multivariate analysis, the route of entry was found to be a significant variable related to polyurethane insulated lead failure (P < 0.05). At lead revision failure to capture was present in 7, oversensing in 4, and undersensing in 2 instances; impedance was < 250 omega in all cases. Pellethane 80A insulated leads are prone to insulation failure, but more when the subclavian vein is used, rather than the cephalic vein.

The retropectoral transaxillary permanent pacemaker: description of a technique for percutaneous implantation of an "invisible" device

This report describes a percutaneous, transaxillary approach for implanting permanent pacemakers in the retropectoral space. This approach was used in 17 patients; indications for the procedure included the need to find a new implantation site in patients with infections and multiple previous pacemaker pocket sites (2 patients), emaciation and absence of sufficient adipose tissue (4 patients), and cosmetic considerations (11 patients). No complications were encountered during the implantation and the results were uniformly excellent in all patients. The pacemaker was "invisible" in each case. We conclude that a percutaneous approach for implanting permanent pacemakers in the retropectoral region is safe and feasible. This approach is likely to be applicable to the implantation of transvenous antitachycardia devices.