Placement of pacemaker leads via the extrathoracic subclavian vein guided by fluoroscopy and venography in the oblique projection

Abstract

Blind needle puncture of the subclavian vein, which is the standard method used for insertion of pacemaker electrodes, causes an increased risk of lead fractures due to entrapment of the lead by the costoclavicular ligament and/or subclavius muscle. The extrathoracic lead insertion technique was developed to prevent such lead fractures. The present study was performed to evaluate the usefulness of extrathoracic subclavian vein puncture under the guidance of both fluoroscopy and venography in the oblique beam projection. Pacemaker leads were implanted in ten patients under the guidance of both fluoroscopy and venography in the ipsilateral anterior oblique projection. The angle of projection was set as large as possible between 35 degrees and 45 degrees . The needle was held parallel to the X-ray angle of incidence and inserted toward the first rib, then withdrawn until the tip entered the subclavian vein. This modified method of pacemaker implantation was successful in all patients, with no complications during the follow-up period ranging from 4 to 19 months. It also prevented pneumothorax and lead entrapment in soft tissue associated with the clavicle that might be caused by the conventional technique.

Novel extrathoracic puncture techniques for pacemaker lead insertion: Pitfalls of the conventional extrathoracic puncture method

“…Therefore, we instead employ a JR40 catheter as a marker to guide extrathoracic puncture. Another puncture method that is performed under the guidance of imaging in the LAO30 position was reported by Harada et al in 2005 [4]. In the posteroanterior (PA) view, the puncture needle is not located parallel to the direction of the X‐ray beam, making it difficult to precisely determine the position of the puncture needle.…”

Navigation by Parallax in Three‐Dimensional Space During Fluoroscopy: Application in Guide Wire‐Directed Axillary/Subclavian Vein Puncture

“…Many different techniques of guiding axillary/subclavian vein puncture by fluoroscopy have been described (Table II). 1,6,[15][16][17][18][19][20] In the navigation mechanism sense, they can be divided into two broad categories: those that commit the needle to a straight trajectory determined from the outset and those that continuously adjust the needle trajectory to direct the tip to the target. All techniques need a target for the needle tip and some means of protecting against pneumothorax.…”

Axillary vein spasm during cardiac implantable electronic device implantation

“…The AV/SV puncture technique, with modifications as to the specifics of its execution, has become a valuable complement to the CV cutdown technique [11,12,14]. The associated injury to the surrounding tissues as well as to the vein itself may induce reflex vascular spasm.…”