Abstract The classic transvenous implantation of a permanent pacemaker in a pectoral loca-tion may be precluded by obstruction of venous access through the superior vena cava or recentinfection at the implant site. When these barriers to the procedure are bilateral and there arealso contraindications or technical difficulties to performing a thoracotomy for an epicardialapproach, the femoral vein, although rarely used, can be a viable alternative.
Acesso femoral venoso: uma alternativa excecional para a implantacão de pacemakerdefinitivo
Resumo A implantacão clássica de pacemaker definitivo (PMD) em posicão antepeitoral e porvia transvenosa pode ser impossibilitada por obstrucão dos acessos venosos à veia cava superior
Radioterapia;Implantacão via veiafemoral
ou pela presenca de infecão recente no mesmo local. Quando estas barreiras são bilateraise, concomitantemente, há contraindicacão ou dificuldade técnica para uma abordagem portoracotomia para implantacão de um eletrocateter epicárdico, a via femoral venosa, embora
raramente utilizada, pode constituir uma alternativa viável.
Descrevemos o caso de uma doente submetida a implantacão de pacemaker definitivo mono-camaral por via femoral direita por apresentar obstrucão de ambos os acessos subclávios e
� Please cite this article as: Tereno Valente B, Conceicão JM, Nogueira da Silva M, et al. Acesso femoral venoso: uma alternativa excecionalpara a implantacão de pacemaker definitivo. Rev Port Cardiol. 2014;33:311.e1---311.e5.
52-year old woman was transferred from her local hospitalor implantation of a permanent pacemaker (PPM) in theontext of symptomatic, intermittent 2:1 atrioventricularlock (AVB).
She had a history of hypothyroidism, controlled byormone replacement therapy, and surgery for Hodgkin’symphoma in 1986, followed by chemotherapy and radio-herapy, and is now in remission with regular assessment inematology consultations.
The patient reported worsening fatigue with dyspnea oninimal exertion and episodes of dizziness for three days,hich had led her to visit the emergency department ofer local hospital. On admission she presented an irregularulse at 53 bpm and the ECG showed 2:1 AVB (Figure 1).aboratory tests showed no ionic changes or thyroid dysfunc-ion and the patient was taking no drugs that would affecttrioventricular conduction. Physical examination revealedxtensive superficial venous circulation over the abdomennd chest.
An attempt at PPM implantation using conventional
enous access failed due to extensive occlusion of bothubclavian veins with widespread superficial and deep veinollateral circulation (Figure 2).
Further cardiological assessment was undertaken withview to performing the procedure using a different
pproach. Transthoracic echocardiography showed signsf constrictive physiology, notably early diastolic septal‘bounce’’ with a notch toward the left ventricle and tri-uspid inflow respiratory variation of over 25%.
High-resolution thoracic contrast computed tomographyCT) (Figure 3) revealed extensive venous collateral circula-ion due to obstruction of the superior vena cava, togetherith marked right pulmonary apical fibrosis and mediastinaleviation to the right. There was minimal space betweenhe posterior face of the sternum and vascular structuresparticularly the origin of the supra-aortic trunks at no morehan 3 mm) which were in contact with the aortopulmonaryindow and the right ventricular free wall. The subxiphoid
egion was in contact with the anterior face of the leftepatic lobe.
Cardiac magnetic resonance imaging confirmed constric-ive physiology and excluded pericardial thickening.
In view of the abnormalities detected, particularly dif-use fibrosis of the thoracic cavity, implantation of anpicardial lead was excluded on medical and surgical eval-ation.
Following confirmation by CT of the patency of vascularccess via the inferior vena cava, it was decided to perform
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PM implantation via the right femoral vein.Given the intermittent nature of the patient’s AVB, the
mbolic risk associated with two intravascular cathetersovering a large territory (from the femoral vein to the
Femoral approach: An exceptional alternative to implant a permanent pacemaker 311.e3
Figure 2 Venography showing total occlusion of the right sub-clavian vein and collateral circulation.
inferior vena cava and right chambers) in a patient withpotential predisposition for venous thromboembolism, andthe risk of atrial lead dislodgment, it was decided to implanta single-chamber PPM.
The procedure was performed under general anesthesia.A longitudinal incision was made in the right groin, a fewcm below the inguinal ligament, enabling visualization ofthe femoral vein (Figure 4). The vein was punctured usingthe Seldinger technique, and a guide wire was inserted intothe vessel, followed by a 7F introducer (Medtronic Inc., Min-neapolis, MN). A 5.7F, 85-cm bipolar active-fixation lead(CapSureFix® Novus 4076-85, Medtronic Inc., Minneapolis,MN) was inserted through the introducer previously pos-itioned in apical-septal position.
Correct positioning of the lead in apical position was con-firmed by detection of a current of injury of >4 mV on theright ventricular electrogram.
Satisfactory sensing and stimulation thresholds wereobtained (sensing 6.6 mV; impedance 630 �; threshold 0.5mV at 0.4 ms), and the introducer was withdrawn, leaving asufficiently large loop in the lead to avoid dislodgement bystretching. The lead was fixed with non-absorbable suturesto the underlying muscle using the suture anchors. A PPMpocket was constructed in the subcutaneous tissue of thelower abdominis muscle on the same side, through a sec-ond incision sufficiently above the inguinal ligament toavoid local discomfort (Figure 5 ). The lead was then tun-neled subcutaneously over the femoral ligament from theinfrainguinal incision to the pocket, and connected to thepacemaker battery (Adapta, Medtronic Inc.).
The procedure was uneventful and the patient wasmobile within 48 hours. The PPM was programmed in VVIRmode with a base rate of 50 bpm, resulting in 35% ventricularpacing, and the system was found to be functioning well incardiology and cardiac pacing consultations after two yearsof follow-up, with no recurrence of the previous symptomsof heart failure. She reported no discomfort or complicationsat the implant site.
Discussion
Unilateral occlusion of the subclavian or innominate veinafter pacemaker or defibrillator implantation is relativelycommon, occurring in approximately 10% of uncomplicated
ard
igure 4 Illustration of the incisions made and course of theead from the insertion site.
mplants. Bilateral occlusion sometimes occurs when bothubclavian access sites have been used for previousmplantations.1 An epicardial approach is the standard alter-ative for cardiac pacing in cases of subclavian occlusion.
Epicardial ventricular pacing can be instituted throughsmall subxiphoid or left lateral incision when tho-
acic anatomy is favorable. Minimally invasive proce-ures for epicardial implantation are possible guided
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4. Bracke FA, van Gelder LM, Sreeram N, et al. Exchange of pacing
Figure 5 Abdominal-pelvic X-ray. DTO: right.
y videothoracoscopy. However, thoracotomy is necessaryhen placing an atrial lead to maintain atrioventricular
ynchrony to minimize the risk of triggering pacemaker syn-rome.
The average operating life of an epicardial lead tends toe shorter than that of an endocardial lead.2,3
As an alternative to epicardial pacing, the subclavian veinn patients with previously implanted leads can be recanal-zed during extraction of the leads by mechanical or laserilatation, using the dysfunctional lead as a guide, thusetaining the classical venous route.4,5 However, the risk oferforation or dislodgment can be high when the occlusions in a territory that has been subjected to radiotherapy.
Almost 33 years ago, El Gamal and Van Gelder6 firstescribed transvenous femoral access for atrial pacing withHelifix lead.In the case presented, we accessed the femoral vein
irectly and inserted the lead well below the inguinal fold torevent discomfort from the scar. A pocket was created inhe abdominal wall, away from the insertion site, to preventhe battery causing any discomfort with thigh movements.
Ellestad et al. also used abdominal wall pockets andeported no major complications in 95 implants.7 Mathurt al. made an incision in the groin skin crease to intro-uce the lead via the femoral vein, and then fashioned theocket cranial to the incision; however, they reported skinrosion in two out of 27 patients.8
An increased incidence of lead fractures might bexpected given the need to U-turn the leads from the venous
ntry site to the generator pocket, but this is not an issueentioned in the literature. The groin is probably a much
ess mobile region than the subpectoral area, especially in
B. Tereno Valente et al.
lderly patients, and does not have an equivalent to thelavicle that can inflict crush injuries.
Dislodgment of atrial leads is a real concern, one of theeasons we opted for a single-chamber PPM in our patient.llestad et al. and Mathur et al. reported a dislodgment ratef 21% and 20%, respectively, even with the use of active-xation leads.6,7 Gravity plays an important role, exerting aorce on the whole length of the lead, which is suspendedrom its anchor point in the myocardium, in contrast to leadsnserted from the pectoral area. Correct positioning of theead is therefore of the utmost importance. Active-fixationeads should not be considered securely attached without aroper current of injury.9
The main aim of positioning the electrocatheter in apical-eptal position in our patient was to increase the amount ofhe lead housed in the ventricular cavity in order to attacht more firmly and maximize the area of subsequent adhe-ions, further increasing lead stability in the long term andeducing the risk of dislodgement.
In conclusion, pacemaker implantation via the femoralein is a good alternative when subclavian vascular accesss unavailable. It is associated with low morbidity and isasy to implement compared with other alternative implantechniques.
thical disclosures
rotection of human and animal subjects. The authorseclare that the procedures followed were in accordanceith the regulations of the relevant clinical research ethicsommittee and with those of the Code of Ethics of the Worldedical Association (Declaration of Helsinki).
onfidentiality of data. The authors declare that they haveollowed the protocols of their work center on the publica-ion of patient data.
ight to privacy and informed consent. The authors havebtained the written informed consent of the patients orubjects mentioned in the article. The corresponding authors in possession of this document.
onflicts of interest
he authors have no conflicts of interest to declare.
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. Tomaske M, Gerritse B, Kretzers L, et al. A 12-year experienceof bipolar steroid-eluting epicardial pacing leads in children. AnnThorac Surg. 2008;85:1704---11.
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. Bracke FA, Meijer A, van Gelder LM. Use of a laser sheath to obtainvenous access in pacemaker lead-related obstruction withoutextraction of the lead. Europace. 2002;4:67---8.
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