FIGURE 59-1 Multiple bilateral abandoned leads with contrast venogram demonstrating occlusion of the left subclavian vein. In this patient, a total of four leads have been implanted via the left subclavian vein, and two via the right subclavian vein. In this situation, if lead-related endocarditis occurs, all hardware must be extracted, and reimplant options are largely limited to the iliac or epicardial routes.
• Traditionally, leads have been implanted via the subclavian vein, which is accessed using either subclavian or axillary vein puncture or cephalic vein cut down.
• When there is obstruction to access through both subclavian veins or the superior vena cava, or when infected leads have recently been extracted from these veins, reimplantation is either precluded or inadvisable using these routes.
• Epicardial lead placement is often possible and may be the best choice if there are ongoing intracardiac vegetations or other concurrent indications for cardiac surgery. Nevertheless, it demands a more invasive procedure, is historically associated with inferior lead survival, and is often accompanied by higher capture thresholds.1
• A variety of alternative intracardiac approaches have been described, including a minithoracotomy with transatrial implant2; and transvenous access via the inferior vena cava, hepatic vein, femoral vein, and iliac vein.3,4
• The iliac vein approach (often mistakenly named “femoral vein” in the original description3 and others) is the most widely accepted transvenous alternative to superior vein access and is particularly useful after extraction for infection.5
• Direct entry to the iliac vein is preferred since this approach avoids flexion of the lead as it crosses the inguinal ligament, which occurs with a true femoral vein approach (though this can also be performed).
ANATOMY
• The femoral vein ascends the thigh, accompanying the femoral artery, receiving several tributaries before reaching the level of the inguinal ligament.
• The inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle.
• The femoral vein becomes the external iliac vein as it passes deep to the inguinal ligament into the abdomen; this is the site of venous access when using the iliac vein technique.
• The external iliac joins the internal iliac to become the common iliac vein; this joins with the contralateral common iliac to become the inferior vena cava.
ILIAC VEIN IMPLANT TECHNIQUE
• The right external iliac vein is most commonly used as this provides a more direct route to the heart, although both are suitable.
• The femoral vein is cannulated using the modified Seldinger technique, and a short 0.035 inch guidewire is introduced as a landmark and the external end secured to the drape using a mosquito or Kelly clamp.
• The inguinal ligament is identified by direct palpation using the bony landmarks described previously.
• A 2-cm incision is made just cephalad to the inguinal ligament, medial to the femoral arterial pulse.
• The incision is carried down to the fascia covering the external oblique.
• The external iliac vein is then cannulated using a direct stick from the fascia under fluoroscopic guidance using the guidewire as a target (Figure 59-2). It is important to keep the needle and attached syringe vertical to avoid puncturing too cephalad, which risks entering the peritoneal cavity, or too caudal, which would enter the femoral vein and produce a tight kink in the lead. This necessitates the operator’s hand being briefly in the X-ray field of view.
FIGURE 59-2 Puncture of the external iliac vein under fluoroscopic guidance, using a guidewire in the vein (introduced from the femoral vein caudal to the access site; arrow) as a target. Note the vertical orientation of the needle with a syringe attached (arrowhead), in the operator’s hand. The site of puncture is just above the pelvic brim.
• As with other transvenous routes of access, it is our practice to puncture the vein separately for each lead, to avoid lead-lead interaction, which can be experienced with the retained guidewire technique. However, this technique may also be used if it is the operator’s preference.
• A long (24-cm) straight peel-away sheath is advanced over the guidewire (such as SafeSheath Long, Pressure Products, San Pedro, CA).
• Long, 75 to 100 cm, active fixation pace/sense or defibrillator leads are used.
• Active fixation leads are preferred as the risk of lead dislodgment is potentially higher with the iliac approach.4
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