Venous percutaneous vein access

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. 

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.)...

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. 

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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