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A method for percutaneous insertion of permanent transvenous pacemaker electrodes
A method for percutaneous insertion of permanent transvenous pacemaker electrodes A method is described for percutaneous insertion of permanent transvenous pacemaker electrodes through the right internal jugular vein by means of a cardiac catheterization sheath. The technique is simple, rapid, and safe, and it has not been associated with any complications.
David L. Gregg, M.D., Philip K. Caves, F.R.C.S., Jefferson H. Hollingsworth, M.D., Alfonso Benedetti, M.D., and Edward B. Stinson, M.D., * Stanford, Calif.
Numerous sites of venous cannulation have been used for insertion of permanent transvenous pacemaker electrodes. All involve operative dissection of the vein to be utilized, followed by venotomy and catheter fixation by either double ligation of the vein or purse-string suture. Isolation of an internal jugular vein for cannulation necessitates a relatively generous incision and incurs a risk of hemorrhage; ligation of this vein may predispose to significant venous thrombosis.' We have developed a new technique for insertion of permanent pacemaker electrodes into the right internal jugular vein. This technique obviates operative dissection and ligation or purse-string suture of the vein. The procedure is rapid and safe and requires only a miniscule incision in the neck. Method and comment
The right internal jugular vein passes beneath a triangle formed by the two heads of the right sternocleidomastoid muscle and the clavicle. Cannulation of the vein at this From the Division of Cardiovascular Surgery, Stanford University Medical Center, Stanford, Calif. 94305. Received for publication Aug. 31, 1973. 'Recipient of an American Heart Association 'Established Investigatorship,
point has been the preferred method for insertion of the central venous catheter at this center for the past 4 years. The technique of cannulation has been described in detail previously. 2 The present method for pacemaker lead insertion begins with a similar trial puncture of the vein with a 1 Y:z inch, 21 gauge needle with the patient in a supine position. After the position of the vein has been determined precisely, a 5.0 mm. horizontal skin incision is made at the superior apex of this triangle. A small space is developed with blunt dissection below the platysma muscle to accommodate a loop of the pacemaker catheter. While the patient performs a Valsalva maneuver, a 16 gauge Medicut* cannula is then introduced into the vein through the stab wound (Fig. 1). The angle of introduction must be acute to the horizontal plane if the pacemaker lead is to lie flat beneath the platysma muscle. The needle is removed, but the polyethylene cannula is left in place. The guide wire of a Desilets-Hoffman cardiac catheterization sheath is then advanced into the vein (Fig. 1). The Medicut cannula is then removed, and the patient is allowed to breathe normally. 'Argyle Medicut intravenous cannulas, 16 gauge times 2 inches, Aloe Medical, St. Louis, Mo.
387
The Journal of
388
Gregg et al.
Thoracic and Cardiovascular Surgery
#16 cannula
~
Sternocleidomastoid
----14
muscle
I
Fig. 1. Steps in the percutaneous insertion of a unipolar pacemaker lead through the right internal jugular vein by means of a cardiac catheterization sheath.
The metal adaptor at the proximal end of a No. 9 Fr. Desilets-HofIman* cardiac catheterization sheath is cut off and discarded. The sheath is then placed over its false catheter, and the unit is threaded over the guide wire and advanced into the internal jugular vein (Fig. 1). The guide wire and false catheter are removed, but the sheath is left in place, protruding 2 to 3 em. from the surface of the skin. The internal diameter of a No. 9 Fr. sheath is suitable for insertion of most unipolar pacemaker leads. In our patients we have utilized the Medtronic permanent transvenous unipolar lead Model 6909, the tip diameter of which is 8 Fr. and the body diameter 7 Fr. This lead can be passed easily through the sheath into the internal jugular vein and manipu• Integra Desilets-Hoffman introducers, No.9 Fr. plied by the United Corporation, A.C.R. N. Y.
radiopaque percutaneous catheter (catelogue No. 8539-S), are supStates Catheter and Instrument Bard Company, Glens Falls,
lated under fluoroscopic control without blood loss or air embolism (Fig. 1). The anatomic relationships of the right internal jugular vein permit direct access to the right ventricle. A 30 degree angle placed in the pacemaker lead 4 to 5 em. from the tip facilitates passage of the lead through the tricuspid valve and into the right ventricular apex. Following threshold determinations and fluoroscopic documentation of satisfactory lead position, the pacemaker lead stylet is removed and the sheath is withdrawn from the vein and skin. The sheath is then incised longitudinally and removed from the lead. A separate incision is made below the clavicle for implantation of the generator pack. The terminal end of the pacemaker lead is then drawn into this incision via a subcutaneous tunnel. The loop of pacemaker lead beneath the platysma muscle is sutured to the subcutaneous tissue, and the neck incision is closed with a single suture of 3-0 nylon. This technique for permanent pacemaker lead insertion has been used without complications in 12 consecutive patients during the past 6 months. We have been impressed with its ease, speed, and cosmetic result. The risk of thromboembolism from percutaneous cannulation of the right internal jugular vein, without ligation of the vein, would appear to be negligible. No instance of thrombosis occurred in this small series of pacemaker patients and, similarly, large vein thrombosis has not been recognized as a complication of this technique for percutaneous insertion of central venous pressure catheters in approximately 2,000 cardiac surgical patients at this institution. Central venous catheters inserted percutaneously into an internal jugular vein under strict sterile technique in cardiac transplant recipients at this center are routinely left in place without complications for the first 4 to 6 postoperative weeks. The low risk of thromboembolism after percutaneous cannulation of an internal jugular vein has been documented as well by others.3-6,
Volume 67 Number
3
Insertion of transvenous pacemaker electrodes
3 89
Morch,1974
REFERENCES Griepp, R. B., Daily, P.O., and Shumway, N. E.: Subclavian-Axillary Vein Thrombosis Following Implantation of a Pacemaker Catheter in the Internal Jugular Vein, J. THORAC. CARDIOVASC. SURG. 60: 889, 1970. 2 Daily, P.O., Griepp, R. B., and Shumway, N. E.: Percutaneous Internal Jugular Vein Cannulation, Arch. Surg. 101: 534, 1970. 3 Hermosura, B., Vanags, L., and Dickey, N. W.: Measurement of Pressure During Intravenous Therapy, J. A. M. A. 195: 321, 1966.
4 Christensen, K. H., Nerstrum, B., and Baden, H.: Complications of Percutaneous Catheterization of the Subclavian Vein in 129 Cases, Acta Chir. Scand. 133: 615, 1967. 5 Leininger, B. J., and Neville, W. E.: Use of the Internal Jugular Vein for Implantations of Permanent Transvenous Pacemaker, Ann. Thorac. Surg. 5: 61, 1968. 6 English, I. C. W., Frew, R. M., and Pigott, J. F. G.: Percutaneous Cannulation of the Internal Jugular Vein, Thorax 24: 496, 1969.
David L. Gregg, M.D., Philip K. Caves, F.R.C.S., Jefferson H. Hollingsworth, M.D., Alfonso Benedetti, M.D., and Edward B. Stinson, M.D., * Stanford, Calif.
Numerous sites of venous cannulation have been used for insertion of permanent transvenous pacemaker electrodes. All involve operative dissection of the vein to be utilized, followed by venotomy and catheter fixation by either double ligation of the vein or purse-string suture. Isolation of an internal jugular vein for cannulation necessitates a relatively generous incision and incurs a risk of hemorrhage; ligation of this vein may predispose to significant venous thrombosis.' We have developed a new technique for insertion of permanent pacemaker electrodes into the right internal jugular vein. This technique obviates operative dissection and ligation or purse-string suture of the vein. The procedure is rapid and safe and requires only a miniscule incision in the neck. Method and comment
The right internal jugular vein passes beneath a triangle formed by the two heads of the right sternocleidomastoid muscle and the clavicle. Cannulation of the vein at this From the Division of Cardiovascular Surgery, Stanford University Medical Center, Stanford, Calif. 94305. Received for publication Aug. 31, 1973. 'Recipient of an American Heart Association 'Established Investigatorship,
point has been the preferred method for insertion of the central venous catheter at this center for the past 4 years. The technique of cannulation has been described in detail previously. 2 The present method for pacemaker lead insertion begins with a similar trial puncture of the vein with a 1 Y:z inch, 21 gauge needle with the patient in a supine position. After the position of the vein has been determined precisely, a 5.0 mm. horizontal skin incision is made at the superior apex of this triangle. A small space is developed with blunt dissection below the platysma muscle to accommodate a loop of the pacemaker catheter. While the patient performs a Valsalva maneuver, a 16 gauge Medicut* cannula is then introduced into the vein through the stab wound (Fig. 1). The angle of introduction must be acute to the horizontal plane if the pacemaker lead is to lie flat beneath the platysma muscle. The needle is removed, but the polyethylene cannula is left in place. The guide wire of a Desilets-Hoffman cardiac catheterization sheath is then advanced into the vein (Fig. 1). The Medicut cannula is then removed, and the patient is allowed to breathe normally. 'Argyle Medicut intravenous cannulas, 16 gauge times 2 inches, Aloe Medical, St. Louis, Mo.
387
The Journal of
388
Gregg et al.
Thoracic and Cardiovascular Surgery
#16 cannula
~
Sternocleidomastoid
----14
muscle
I
Fig. 1. Steps in the percutaneous insertion of a unipolar pacemaker lead through the right internal jugular vein by means of a cardiac catheterization sheath.
The metal adaptor at the proximal end of a No. 9 Fr. Desilets-HofIman* cardiac catheterization sheath is cut off and discarded. The sheath is then placed over its false catheter, and the unit is threaded over the guide wire and advanced into the internal jugular vein (Fig. 1). The guide wire and false catheter are removed, but the sheath is left in place, protruding 2 to 3 em. from the surface of the skin. The internal diameter of a No. 9 Fr. sheath is suitable for insertion of most unipolar pacemaker leads. In our patients we have utilized the Medtronic permanent transvenous unipolar lead Model 6909, the tip diameter of which is 8 Fr. and the body diameter 7 Fr. This lead can be passed easily through the sheath into the internal jugular vein and manipu• Integra Desilets-Hoffman introducers, No.9 Fr. plied by the United Corporation, A.C.R. N. Y.
radiopaque percutaneous catheter (catelogue No. 8539-S), are supStates Catheter and Instrument Bard Company, Glens Falls,
lated under fluoroscopic control without blood loss or air embolism (Fig. 1). The anatomic relationships of the right internal jugular vein permit direct access to the right ventricle. A 30 degree angle placed in the pacemaker lead 4 to 5 em. from the tip facilitates passage of the lead through the tricuspid valve and into the right ventricular apex. Following threshold determinations and fluoroscopic documentation of satisfactory lead position, the pacemaker lead stylet is removed and the sheath is withdrawn from the vein and skin. The sheath is then incised longitudinally and removed from the lead. A separate incision is made below the clavicle for implantation of the generator pack. The terminal end of the pacemaker lead is then drawn into this incision via a subcutaneous tunnel. The loop of pacemaker lead beneath the platysma muscle is sutured to the subcutaneous tissue, and the neck incision is closed with a single suture of 3-0 nylon. This technique for permanent pacemaker lead insertion has been used without complications in 12 consecutive patients during the past 6 months. We have been impressed with its ease, speed, and cosmetic result. The risk of thromboembolism from percutaneous cannulation of the right internal jugular vein, without ligation of the vein, would appear to be negligible. No instance of thrombosis occurred in this small series of pacemaker patients and, similarly, large vein thrombosis has not been recognized as a complication of this technique for percutaneous insertion of central venous pressure catheters in approximately 2,000 cardiac surgical patients at this institution. Central venous catheters inserted percutaneously into an internal jugular vein under strict sterile technique in cardiac transplant recipients at this center are routinely left in place without complications for the first 4 to 6 postoperative weeks. The low risk of thromboembolism after percutaneous cannulation of an internal jugular vein has been documented as well by others.3-6,
Volume 67 Number
3
Insertion of transvenous pacemaker electrodes
3 89
Morch,1974
REFERENCES Griepp, R. B., Daily, P.O., and Shumway, N. E.: Subclavian-Axillary Vein Thrombosis Following Implantation of a Pacemaker Catheter in the Internal Jugular Vein, J. THORAC. CARDIOVASC. SURG. 60: 889, 1970. 2 Daily, P.O., Griepp, R. B., and Shumway, N. E.: Percutaneous Internal Jugular Vein Cannulation, Arch. Surg. 101: 534, 1970. 3 Hermosura, B., Vanags, L., and Dickey, N. W.: Measurement of Pressure During Intravenous Therapy, J. A. M. A. 195: 321, 1966.
4 Christensen, K. H., Nerstrum, B., and Baden, H.: Complications of Percutaneous Catheterization of the Subclavian Vein in 129 Cases, Acta Chir. Scand. 133: 615, 1967. 5 Leininger, B. J., and Neville, W. E.: Use of the Internal Jugular Vein for Implantations of Permanent Transvenous Pacemaker, Ann. Thorac. Surg. 5: 61, 1968. 6 English, I. C. W., Frew, R. M., and Pigott, J. F. G.: Percutaneous Cannulation of the Internal Jugular Vein, Thorax 24: 496, 1969.