Percutaneous venous access

Initially, almost all pacemaker and ICD procedures were approached exclusively from the epicardial point of view. But with the development of a transvenous approach, either by cutdown or percutaneous techniques, now almost aU pacemaker and ICD procedures are approached on a transvenous or nonthoracotomy basis. Today, the epicardial approach is reserved for certain unique circumstances. Electrodes can be placed on the epicardium by a variety of techniques. This involves a subxiphoid incision, and limited thoracotomy, or direct application of electrodes on an exposed heart. Recently, mediastinoscopy and thoracoscopy have been used to apply permanent pacing and rate-sensing electrodes as well as patch electrodes. The transvenous approach can be performed by venous cutdown, percutaneous venous access, or a combination of the two. 

Byrd underscores the concept of thoroughly understanding anatomy with his description of the anteriorly and posteriorly displaced clavicle (44). The posteriorly displaced clavicle commonly seen in chronic obstructive pulmonary disease patients can make venous access from the percutaneous point of view extremely hazardous. Similarly, the anteriorly displaced clavicle, as found in the elderly kyphoscoliotic patient with interiorly bowed clavicles, renders percutaneous venous access next to impossible. An appreciation of these anatomic variations is essential to avoid the complications of pneumothorax, hemopneumothorax, and unsuccessful venipuncture. It should also be appreciated that the right ventricle is an anterior structure, the apex of which is usually located anteriorly and to the left (Fig. 4.5). Although the normal location is distinctly to the left of the midline, occasionally it can be rotated anteriorly... 

Fig. 4.27 Percutaneous venous access of the right internal jugular vein. Weitlaner retractor placed demonstrating the figure-of-eight stitch. (From Belott PH, Reynolds DW. Permanent pacemaker implantation. In EUenbogen KA, Kay N, Wilkoff BL, eds. Clinical cardiac pacing. Philadelphia WB Saunders, 1995, with permission.)...

Table 4.10 Venous access for dual-chambered pacing. Venous cutdown Isolate one or two veins Percutaneous Two separate sticks and sheath applications Percutaneous Two electrodes down one large sheath Percutaneous Retained guidewire (Belott technique)...

Dual-chambered pacing calls for the introduction of an atrial and ventricular electrode. The cutdown technique is less suited for this approach because all too often the cephalic vein can hardly acconunodate one electrode, and even less two. The percutaneous approach appears ideally suited for dual-chambered pacing as there is potential for unlimited access to the venous circulation. Various options for dual-chambered pacing venous access are listed in Table 4.10. There are four percutaneous approaches for dual-chambered pacing. 

Frequently, the solution to one problem creates another problem. A case in point is this author s proposed extreme medial subclavian percutaneous technique. Although this approach is safe, avoids the complication of pneumothorax, and expedites venous access, it has been implicated in the case of... 

Venous access can be carried out by either cutdown or the percutaneous approach. If the initial electrode has been placed via cutdown, the isolation of a second vein for venous access will prove extremely difficult. In this case, percutaneous approach should be attempted. Conversely, if the initial electrode has been placed percutaneously, then a second percutaneous approach or a cut-down is always possible. The second percutaneous puncture is usually carried out just lateral to the initial venous entry site. The initial lead can be used as a marker of the venous anatomy. If any difficulty is encountered, fluoroscopy is used to guide the lead using the chronic ventricular lead for reference (85,86). There is potential risk of damaging the initial electrode and care should be taken to avoid its direct puncture. The use of radiographic materials can also help define the venous structure as well as its patency. 

In a similar approach, pacemaker leads have been placed via transhepatic cannulation (Fig. 4.64) (118). Venous access is achieved percutaneously with the guidewire passed transhepaticaUy, the sheath set is applied, allowing the subsequent introduction of a permanent pacing electrode. Once again, this procedure has been reserved for complex congenital anomahes that preclnde venous access via a superior vein. 

Belott PH. Bhnd percutaneous axillary venous access. PACE 1998 21 873. 

Method Nasogastric, nasojejunal, percutaneous gastrostomy, percutaneous jejunostomy Fine bore peripheral cannulae or (for prolonged use) central venous access... 

Central venous catheters are reluctantly used as blood access for hemodialysis because of safety concerns and frequent complications, for example sepsis, thrombosis, and vessel stenosis. Nevertheless, 20% or more of all patients rely on atrial catheters for chronic dialysis because of lack of other access. Potentially fatal risks related to central venous catheters include air embolism (1), severe blood loss (2), and electric shock (3). These specific risks have been substantially eliminated by the inherent design and implantation of Dialock (Biolink Corporation, USA). Dialock is a subcutaneous device consisting of a titanium housing with two passages with integrated valves connected to two silicone catheters. The system is implanted subcutaneously below the clavicle. The tips of the catheters are placed in the right atrium. The port is accessed percutaneously with needle cannulas. 

Fig.1. 39 Subclavian venous system and skeletal landmarks relevant to percutaneous access. Subclavius muscle and costoclavicular ligament complex are shown between the clavicle and the first rib (from [29], Chap. 5, p. 212, by permission of Mayo Foundation for Medical Education and Research. All rights reserved)...

Catheter device selection is based on a number of factors, including the plarmed application and placement site, duration of implantation, composition of fluids infused, and frequency of access (Namyslowski and Patel, 1999). Vascular catheters can be divided into two genei groups shortterm, temporary catheters that are placed percutaneously, and long-term, indwelling vascular catheters that usually require a surgical insertion. Temporary catheters include short peripheral venous and arterial catheters, nontunneled central venous and arterial catheters, and peripherally inserted central catheters (Pearson, 1996). Tunneled central venous catheters and totally implantable intra-... 

As mentioned, the goal of EVTA is to endove-nously deliver sufficient thermal energy to the wall of an incompetent vein to irreversibly occlude it. A catheter inserted into the venous system either by percutaneous access or by open venotomy delivers the thermal energy. The procedure can be performed on an ambulatory basis with local anesthetic and generally require little or no sedation. The patients are generally fully ambulatory following treatment and the recovery time is short. 

Type II is a mid-vein cannulable segment stenosis and should be first treated with PTA (percutaneous transluminal angioplasty) in autogenous accesses in order to preserve the length of the needling site of the vein however, in case of failure an interposition graft should be inserted [4]. In this type of lesions, the dialysis dose is usually not affected because the stenosis often falls between the arterial and venous needles [5],... 

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