Suture placement

Placement of vascular access ports is similar to that of a long-term indwelling arterial catheter. A small incision is made over the selected vein and a second incision is made lower in the anterior chest to create a pocket to house the port. The catheter is tuimeled subcutaneously from its entry point into the vein with the tip inside the right atrium. The final position of the catheter is verified by fluoroscopy, secured with sutures, and the subcutaneous pocket is closed. The port septum is easily palpable transcutaneously, and the system may be used immediately. A surgeon typically inserts the vascular access port in an outpatient setting. 

Intracanal endodontic treatment after placement and buildup Placement of rubber dams Postoperative suture removal... 

Numerous companies have developed devices and techniques to treat mitral annular dilatation percutane-ously. Most of these devices take advantage of the close anatomic proximity of the coronary sinus to the posterior aspect of the mitral valve annulus, and involve the placement of a prosthetic device in the coronary sinus to decrease the anterior-posterior diameter of the mitral valve annulus, thereby improving mitral leaflet coaptation. Other techniques involve percutaneous direct plication of the mitral annulus with sutures or the use of a bridge to connect a coronary sinus anchor and a septal anchor. 

Placement of an annuloplasty ring is a common surgical approach for treatment of mitral regurgitation. There are currently a number of novel devices designed to simulate suture mitral annuloplasty surgery percuta-neously. All are currently in preclinical and early pilot clinical phase of development. 

Once successful ventricular lead placement has been achieved, the lead must be secured. The first step in this process is withdrawal of the lead stylet to the vicinity of the lower right atrium (89) (Fig. 4.38). The stylet is not totally removed, but retained to add support if a second lead is to be placed. With a straight ventricular lead stylet in the vicinity of the lower right atrium, the lead is anchored at the venous entry site. The lead suture sleeve should be used for anchoring to avoid lead injury. Care is also taken not to cut through the suture sleeve and also injure the lead. Once the ventricular lead is anchored and after no further leads are to be added, the lead stylet is removed. 

Occasionally ICD systems require the placement of additional leads and/or patches to achieve adequate DFTs. An additional patch electrode may be added through a small, left anterior chest incision (Fig. 4.57). This incision is generally placed along the left inframammary skin fold. A subcutaneous pocket is developed and a supplemental patch placed. The patch is sutured to the chest wall. The proximal lead is then tunneled to the ICD. A variation on this system is the subcutaneous array developed by CPI (Fig. 4.58). The array consists of three flexible defibrillator leads that are joined at a common connector. The leads are designed to be placed subcutaneously along the contour of the chest wall. The leads fuse as a common electrode that connects to the ICD. Creating a small incision in the left lateral inframammary skin fold places the array. Three separate subcutaneous tracts are created using a blunt-tipped malleable stylet. The stylet is loaded with a sheath that is advanced down each traa. The stylet is removed and the limbs of the array are passed down each sheath. 

Fig. 4.68 Atrial lead placement through atriotomy and purseslring suture. Atrium and ventricular electrodes are positioned and the atriotomy is secured. (Westerman GR, Van Devanter SH. Transthoracic transatrial endocardial lead placement for permanent pacing. Ann Thorac Surg 1987 43(4) 445-446, with permission.)...

Fig. 4.69 Atrial lead placement. Insert in the upper right shows atrial endocardial lead being placed through the wall of the right atrial appendage with the tip of the pacemaker lead abutting the endocardial surface. A pursestring suture is placed around the lead at the point of entry. The relationship of the atrial lead is also shown. (Hayes DL, Vhetstra RE, Puga FJ, et al. A novel approach to atrial endocardial pacing. Pacing Clin Electrophysiol 1989 12(1 Pt 1) 125-130, with permission.)...

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