Aleksic Ivan, Kottenberg-Assenmacher Eva, Kienbaum Peter, Szabo Andras K, Sommer Sebastian-Patrick, Wieneke Heiner, Yildirim Cagatay, Leyh Rainer G
Departments of Thoracic and Cardiovascular Surgery, West-German Heart Center, Essen, Germany.
Pacing Clin Electrophysiol. 2007 Aug;30(8):957-60. doi: 10.1111/j.1540-8159.2007.00792.x.
Venous complications of implantable cardioverter defibrillator (ICD) systems may cause significant problems when the need for system revision or upgrades arises. Such revisions require venous access close to the site of the previous ICD implantation. The internal and external jugular vein have disadvantages due to a long subcutaneous course crossing the clavicle and problems with lead extraction if infection occurs.
In seven patients with ICD revisions due to lead dysfunction (n = 4) and upgrade to a biventricular device (n = 2) and status after system removal due to infection with new device implantation (n = 1) conventional venous access could not be obtained. Intraoperative contrast venography demonstrated an occluded left subclavian and/or left innominate vein in all patients. In all patients, we gained venous access through puncture of the right innominate vein and tunneled the new lead subcutaneously to the ICD pocket on the left.
No intraoperative complications were observed. All patients are followed in our ICD clinic. Mean follow-up is 16 +/- 4 months now. So far, no clinical or lead complications with this access have been observed.
We have demonstrated that ICD lead placement through puncture of the right innominate vein is feasible. We propose the innominate vein as an alternative route for establishing venous access in patients requiring ICD revisions or upgrades who suffer from venous obstruction. ICD implanting physicians should acquaint themselves with the technique of right innominate vein puncture to use this vein as a bail-out strategy in patients with complicated venous access.
当需要对植入式心脏复律除颤器（ICD）系统进行修订或升级时，ICD系统的静脉并发症可能会引发严重问题。此类修订需要在先前ICD植入部位附近进行静脉穿刺。颈内静脉和颈外静脉存在一些缺点，因为它们在皮下走行较长，会穿过锁骨，并且如果发生感染，在拔除导线时会出现问题。
7例因导线功能障碍进行ICD修订（n = 4）、升级为双心室装置（n = 2）以及因感染拔除系统并植入新装置后（n = 1）的患者，无法获得传统的静脉通路。术中造影静脉成像显示所有患者的左锁骨下静脉和/或左无名静脉闭塞。在所有患者中，我们通过穿刺右无名静脉获得静脉通路，并将新导线经皮下隧道引至左侧的ICD囊袋。
未观察到术中并发症。所有患者均在我们的ICD门诊接受随访。目前平均随访时间为16±4个月。迄今为止，通过这种通路未观察到临床或导线相关并发症。
我们已经证明，通过穿刺右无名静脉进行ICD导线植入是可行的。我们建议将无名静脉作为在需要进行ICD修订或升级但存在静脉阻塞的患者中建立静脉通路的替代途径。ICD植入医生应熟悉右无名静脉穿刺技术，以便在静脉通路复杂的患者中作为一种补救策略使用该静脉。
