title: Supraclavicular vein approach to overcoming ipsilateral chronic subclavian vein obstruction during pacemaker-ICD lead revision or upgrading.
abstract: OBJECTIVE
  We report our experience with the supraclavicular vein approach of subclavian vein puncture to overcome ipsilateral chronic obstruction when implanting pacemaker or implantable cardioverter defibrillator leads.
  
  
  RESULTS
  The subclavian vein obstruction was documented by venography. The skin was punctured with an 18-gauge needle, 1 cm lateral to the lateral head of the sternocleidomastoid muscle and 1 cm cranial to the clavicle. The needle was directed under and close to the clavicle pointing to the sternal notch. Once the vein was successfully punctured, medial to the obstruction, a 0.38 in. guidewire was inserted into the venous bed. A peel-away sheath was indwelled using the Seldinger technique. The leads were placed in the standard fashion; they were secured by suture to the subcutaneous tissue of the fossa supraclavicularis major using a protective sleeve. The proximal portion of the lead was tunnelled over the clavicle down to the device's prepectoral pocket. Lead insertion was performed in four patients (twice in one patient) with total left subclavian vein obstruction; the site of the obstruction was in the mid-segment of the left subclavian vein in two patients, in the axillary and distal segment of the subclavian vein in one patient, and in the distal segment of the subclavian vein in one patient. There were no complications with the surgical wound and the lead parameters remained stable.
  
  
  CONCLUSIONS
  The supraclavicular approach of the subclavian vein puncture to overcome ipsilateral total occlusion is feasible and safe.
authors.affiliation: Department of Cardiology, HaEmek Medical Center, 18100 Afula, Israel. antonelli_dante@hotmail.com
authors.forename: Dante
authors.initials: D
authors.lastname: Antonelli
authors.forename: Nahum A
authors.initials: NA
authors.lastname: Freedberg
authors.forename: Yoav
authors.initials: Y
authors.lastname: Turgeman
mesh_terms: D000368:Aged; D002404:Catheterization; D002908:Chronic Disease; D002968:Clavicle / Q000000981:diagnostic imaging; D017147:Defibrillators, Implantable; D004567:Electrodes, Implanted; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D010690:Phlebography; D019919:Prosthesis Implantation; D013350:Subclavian Vein / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome; D014689:Venous Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*