Kloosterman Esteban M, Rosman Jonathan, Rosenbaum Murray
Department of Cardiology, Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, Boca Raton, FL, USA.
Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA.
J Innov Card Rhythm Manag. 2019 Apr 15;10(4):3593-3599. doi: 10.19102/icrm.2019.100404. eCollection 2019 Apr.
Inadequate thickness of subcutaneous tissue, pectoralis muscle wasting, and/or a lack of availability of subpectoral space can become significant issues in patients with or requiring cardiovascular implantable electronic devices (CIEDs). This is particularly concerning but not exclusive in the elderly population, who may experience discomfort and hypersensitivity of the site as well as the potential for erosion and an increased risk of infection. Thus, the use of an alternative location, the axillary fossa, offers several advantages that make it a suitable option. Specifically, it usually has a preserved fat pad (even in thin patients); is unperturbed by arm movement; is not directly exposed to contact; is easily accessed with no significant compromise of neurovascular structures; and is near the conventional subclavicular sites, with enough lead length to reach in case of the need for generator replacement. Here, we present a series of five patients, including details of their anatomy and the implant techniques used. Two underwent device replacements, with one of them presenting with significant ongoing site discomfort and the other with extreme tissue thinning, respectively. Two patients with no significant fat layer or pectoral muscle wasting had new pacemakers implanted. Lastly, a biventricular implantable cardioverter-defibrillator generator was reimplanted in a younger patient who had issues with protrusion and discomfort in the setting of thin subcutaneous tissue and the subpectoral space being occupied by a large breast implant. In conclusion, the use of the axillary fossa as a new alternative CIED implantation site, using the proposed implant technique, appears feasible and safe and demonstrated excellent results related to patient comfort and adequate device cover in five cases.
皮下组织厚度不足、胸肌萎缩和/或胸大肌下间隙不足，对于植入或需要植入心血管植入式电子设备（CIED）的患者而言，可能会成为重大问题。这在老年人群中尤为值得关注，但并非仅见于该人群，他们可能会出现植入部位的不适和过敏，以及发生侵蚀和感染风险增加的可能性。因此，选择腋窝作为替代植入部位具有诸多优势，使其成为一个合适的选择。具体而言，腋窝通常有保留的脂肪垫（即使是体型消瘦的患者）；不受手臂活动干扰；不会直接暴露于接触中；易于触及且不会对神经血管结构造成重大损伤；并且靠近传统的锁骨下植入部位，在需要更换发生器时，有足够的导线长度能够到达。在此，我们报告了5例患者，包括他们的解剖结构细节和所采用的植入技术。其中2例进行了设备更换，分别有1例持续存在严重的植入部位不适，另1例出现了严重的组织变薄。2例没有明显脂肪层或胸肌萎缩的患者植入了新的起搏器。最后，1例年轻患者重新植入了双心室植入式心律转复除颤器发生器，该患者存在皮下组织薄以及胸大肌下间隙被大的乳房植入物占据的情况，导致了植入物突出和不适。总之，采用所建议的植入技术，将腋窝作为CIED植入的新替代部位似乎是可行且安全的，并且在5例患者中均显示出与患者舒适度和设备覆盖良好相关的优异结果。
