Venous Approaches

Fig 1.5 This patient was referred to our institution for lead extraction using the internal transjugular venous approach. The fractured lead ( ) was implanted in 1975. Note that the old lead has an electrode with a broader stimulating electrode surface area. Temporary pacing lead (°)... 

Classically, the venous approach establishes where the device will be implanted. Historically, the venous approach used for lead implantation was the ileofemoral vein. Once a small incision immediately below the inguinal ligament was performed, the operator had to carry the dissection down to the fascia above the vein. At this point, the iliac vein was entered with a standard puncture technique, and after lead implantation, it was tunneled to the abdominal pocket. For this venous approach, the device was actually housed in the abdominal region. The pocket was created lateral to the umbilicus and superficial to the rectus sheath [30, 31]. This is not the standard method for PM implantation used today, but it is important to know this approach in the event that more com-... 

Another venous lead implantation approach of historical interest is the jugular vein. The first method to acces the vein was nonpercutaneous, in which two incisions are required. The first skin incision, performed above the clavicle between the posterior rim of the sternocleidomastoid muscle and the anterior rim of the trapezius muscle, is necessary to reach the external jugular vein or, extended forward, the carotid sheath wherein internal jugular vein is present. A second infraclavicu-lar incision is then necessary to fashion the pocket over the pectoral muscle. Only the latter is required for the percutaneous approach, but regardless of the method used, in both cases, the lead must be tunneled to the pocket (usually over the clavicle). These techniques have been abandoned due to frequent complications related to lead failure. Outside the vein, the lead must run at an acute angle to reach the pocket, which is the reason for the recurrent lead fracture related to this venous approach. However, this is probably the better approach in case of lead extraction. 

Bongiomi MG, Soldati E, Zucchelli G et al (2008) Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches high success rate and safety in more than 2000 leads. Eur Heart J 29 2886-2893... 

Most operators begin with a venous entry approach using the implant vein and switch to a transfemoral approach if necessary [30]. Moreover, when leads are broken or free floating, the transfemoral approach is historically performed. Different venous approaches using the mechanical dilatation tech-... 

A procedural strategy is then developed and discussed with the team regarding anesthesia type (local, heavy sedation, general), technique, and type of venous approach, and all necessary tools are checked in the cath lab or surgical room. The procedure can fail if a particular tool is missing. The surgeon is informed about the procedure to ensure surgical standby. 

The internal jugular venous approach is used as (1) a first choice in the presence of free-floating leads with attached tip (2) in case of an unsuccessful approach from the venous entry site. 

Under these conditions, a possible solution is to change the venous approach in order to change the position of the proximal part of the LV lead. The straightest path into the coronary sinus is from the femoral vein. The LV lead can be made free floating by grasping it in the right atrium and then sliding it into the inferior vena cava (IVC). In some... 

The axillary venous approach was initially reported in 1987 by Nichalls as an alternate site of venous access for large central lines (67). Nichalls developed a technique from cadaver dissection by which he estabUshed reliable landmarks. He defined the axillary vein as an infraclavicular structure. In his technique, the needle is always anterior to the thoracic cavity, generally... 

Lead passage and placement via right venous access is intrinsically difficult because of the multiple natural acute angles and bends that are encountered from this approach. Just as a left venous approach forms a gentle C-shaped curve that is counterclockwise, the right venous access results in a clockwise curve that directs the electrode to the right lateral atrial wall when the curved stylet is in place (Fig. 4.34). It then takes considerable skill, ingenuity, and even luck to cross the tricuspid valve. Because the lead tip consistently points to the... 

Koos R, Sinha AM, Markus K, Breithardt OA, Mischke K, Zarse M, Schmid M, Autschbach R, Hanrath P, Stellbrink C. Comparison of left ventricular lead placement via the coronary venous approach versus lateral thoracotomy in patients receiving cardiac resynchronization therapy. Am J Cardiol 2004 94 59-63. 

Antonelli D, Rosenfeld T, Freedberg NA, et ah. Insulation lead failure Is it a matter of insulation coating, venous approach or both PACE 1998 21 418-421. 

Peuster M, Windhagen-Mahnet B, Fink F et al. (1998) Interventional therapy for hemangioendothelioma of the liver in a newborn infant using a central venous approach. Z Kardiol 87 832-836... 

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