Al-Bataineh Mohammad, Sajadi Saeid, Fontaine John M, Kutalek Steven
Department of Medicine, Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
J Interv Card Electrophysiol. 2010 Mar;27(2):137-42. doi: 10.1007/s10840-009-9444-1.
The prepectoral approach is the procedure of choice for pacemaker or defibrillator (device) implantation. Epicardial or transiliac approaches are reserved for patients in whom the pectoral approach is not feasible. We studied the viability of the axillary subpectoral approach for implanting devices in patients in whom the standard prepectoral approach was not feasible.
Devices and leads were extracted from 16 patients with infected devices in the prepectoral position. The contralateral site was unsuitable for reimplantation because of infection or inadequate venous access. On the side ipsilateral to that with prior prepectoral device infection, we made an incision on the anterior axillary line along the border of the pectoralis major; dissection was continued below the muscle to create a pocket for generator implantation. Axillary venous puncture was performed from the axillary incision and beneath the pectoralis major muscle using a long 14-gauge needle. Long guidewires and peel-away sheaths were used for positioning the lead. The generator was placed in the subpectoral pocket; the wound was closed with absorbable sutures.
One patient developed a pocket hematoma; one developed a pneumothorax; no other surgical complication, lead malfunction, or recurrence of infection was observed.
The axillary subpectoral approach is an acceptable, technically feasible method for reimplantation for patients with pectoral device infection and limited venous access options. It offers the advantage of a new sterile fascial plane ipsilateral to the site of prepectoral device infection.
胸肌前入路是起搏器或除颤器（器械）植入的首选方法。心外膜或经髂入路则用于胸肌前入路不可行的患者。我们研究了腋胸肌下入路在标准胸肌前入路不可行的患者中植入器械的可行性。
从16例胸肌前位置器械感染的患者中取出器械和导线。对侧部位因感染或静脉通路不佳而不适合重新植入。在先前胸肌前器械感染同侧，沿胸大肌边界在腋前线做切口；在肌肉下方继续解剖以创建用于植入发生器的囊袋。使用一根14号长针从腋窝切口并在胸大肌下方进行腋静脉穿刺。使用长导丝和可剥离鞘管来定位导线。将发生器置于胸肌下囊袋中；用可吸收缝线关闭伤口。
1例患者出现囊袋血肿；1例出现气胸；未观察到其他手术并发症、导线故障或感染复发。
对于胸肌前器械感染且静脉通路选择受限的患者，腋胸肌下入路是一种可接受的、技术上可行的重新植入方法。它具有在胸肌前器械感染部位同侧形成新的无菌筋膜平面的优势。
