Venous percutaneous approach

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. 

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. 

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. 

Transcoronary venous injection is performed with a catheter system threaded percutaneously into the coronary sinus. Initial studies in swine have confirmed the feasibility and safety of this approach [121]. This delivery method has also been used to deliver skeletal myoblasts to scarred myocardium in cardiomyopathy patients [120]. With intravascular ultrasound guidance, this approach allows the operator to extend a catheter and needle away from the pericardial space and coronary artery into the adjacent myocardium. To date, human feasibility studies have had a good safety profile. This technique is limited, however, by coronary venous tortuosity, lack of site specific targeting, and its own technically challenging nature. Unlike the transendocardial approach, in which cells are... 

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. 

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... 

Fig. 4.19 Deep (A) and superficial (B) anatomic relationships of the Magney approach to subclavian vena puncture. Point M indicates the medial end of the clavicle. X defines a point on the clavicle directly above the lateral edges of the clavicular/subclavius muscle (tendon complex). Rl. Point D overlies the center of the subclavian vein as it crosses the first rib. St, the center of the sternal angle Cp, coracoid process Ax, axillary vein star, costoclavicular ligament open circle with closed circle, costoclavicular ligament open circle with closed circle inside, costoclavicular ligament sm, subclavius muscle. The arrow points to Magney s ideal point for venous entry. (Magney JE, Staplin DH, Flynn DM, et al. A new approach to percutaneous subclavian venipuncture to avoid lead fracture or central venous catheter occlusion. Pacing Clin Electrophysiol 1993 16(11) 2133-2142, with permission.)...

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. 

Magney JE, Staplin DH, Flynn DM, et al. A new approach to percutaneous subclavian needle puncture to avoid lead fracture or central venous catheter occlusion. PACE 1993 16 2133. 

GI or bihary tract. Preinterventional contrast-enhanced CT performed in an arterial and venous phase enables the operator to differentiate clearly surrounding organs and vessels. A transgastric approach may be chosen for placement, which can be later used for transgastric stent placement (internal drainage) between the pseudocyst and the stomach. In case the pseudocyst communicates with the pancreatic duct, duration of percutaneous drainage may take up to 8-12 weeks. 

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