Inside-out access: a new method of lead placement for patients with central venous occlusions.
BACKGROUND
Physicians will increasingly encounter patients who require rhythm management devices but have venous obstructions that prevent conventional access. Alternate access options, such as thoracotomy or transiliac approaches, exist but are associated with greater cost and morbidity.


OBJECTIVE
The purpose of this study is to describe a novel method of vascular access that allows prepectoral placement of conventional pacing and defibrillation leads in patients with complex central venous occlusions.


METHODS
Eight patients with central venous occlusions were referred for device implantation. Inside-out central venous access (IOCVA) was obtained via a percutaneous femoral approach. A catheter-dilator system was advanced via the right atrium to the most central point of venous occlusion. The occluded vein segment was punctured with a directionally guided needle, which was advanced along intravascular or extravascular tissue planes to the subclavian region. A solid wire needle was oriented toward the skin surface and advanced through the soft tissues until it exists from the body. The wire was used to pull rigid dilators through the occluded segment. Standard transvenous leads were implanted though the newly created channel.


RESULTS
All patients with total central venous occlusions (4 superior vena cava, 4 brachiocephalic and bilateral subclavian) had successful, prepectoral device implants (4 left-sided, 1 single-chamber, 4 dual-chamber, 3 biventricular). No procedure-related complications occurred. All patients had normal device function at follow-up of 485 ± 542 days.


CONCLUSIONS
IOCVA is an effective method of pacemaker and defibrillator implantation for patients with central venous occlusions. Further clinical evaluation of this novel method is needed.
Gill Heart Institute, the Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky, USA.
Claude S
CS
Elayi
Christopher L
CL
Allen
Steve
S
Leung
Stephanie
S
Lusher
Gustavo X
GX
Morales
Matthew
M
Wiisanen
Shamik
S
Aikat
Bahram
B
Kakavand
Jignesh S
JS
Shah
David J
DJ
Moliterno
John C
JC
Gurley
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017147:Defibrillators, Implantable; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D019919:Prosthesis Implantation / Q000379:methods*; D013349:Subclavian Steal Syndrome / Q000150:complications* / Q000000981:diagnostic imaging; D013479:Superior Vena Cava Syndrome / Q000150:complications* / Q000000981:diagnostic imaging; D016896:Treatment Outcome