title: Novel experience of laser-assisted 'inside-out' central venous access in a patient with bilateral subclavian vein occlusion requiring pacemaker implantation.
abstract: OBJECTIVE
  This new laser facilitated 'inside-out' technique was used for transvenous pacemaker insertion in a pacemaker-dependent patient with bilateral subclavian occlusion and a failed epicardial system who is not suitable for a transfemoral approach.
  
  
  RESULTS
  Procedure was undertaken under general anaesthesia with venous access obtained from right femoral vein and left axillary vein. 7F multipurpose catheter was used to enter proximal edge of the occluded segment of subclavian vein via femoral approach, which then supported stiff angioplasty wires and microcatheters to tunnel into the body of occlusion. When encountered with impenetrable resistance, 1.4 mm Excimer laser helped delivery of a Pilot 200 wire, which then progressed towards the distal edge of occlusion. Serial balloon dilatations allowed wire tracked into subintimal plane, advanced towards left clavicle using knuckle wire technique, which was then externalized with blunt dissection from infraclavicular pocket area. It was later changed to Amplatz superstiff wire exiting from both ends to form a rail, which ultimately allowed passage of pacing leads after serial balloon dilatation from clavicular end.
  
  
  CONCLUSIONS
  Our hybrid 'inside-out' technique permitted transvenous pacemaker insertion without complication and this is, to our knowledge, the first case using laser in this context.
authors.affiliation: Department of Cardiology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK.
authors.forename: Thandar
authors.initials: T
authors.lastname: Aye
authors.affiliation: Department of Cardiology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK.
authors.forename: Thanh Trung
authors.initials: TT
authors.lastname: Phan
authors.affiliation: Department of Cardiology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK.
authors.forename: Douglas Findlay
authors.initials: DF
authors.lastname: Muir
authors.affiliation: Department of Cardiology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK.
authors.forename: Nicholas John
authors.initials: NJ
authors.lastname: Linker
authors.affiliation: Department of Radiology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough TS4 3BW, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Hartley
authors.affiliation: Department of Cardiology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK.
authors.forename: Andrew John
authors.initials: AJ
authors.lastname: Turley
mesh_terms: D017222:Angioplasty, Balloon, Laser-Assisted / Q000295:instrumentation*; D006328:Cardiac Catheterization / Q000295:instrumentation*; D002304:Cardiac Pacing, Artificial; D002405:Catheterization, Central Venous / Q000295:instrumentation*; D003251:Constriction, Pathologic; D004867:Equipment Design; D006327:Heart Block / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D054018:Lasers, Excimer / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D010690:Phlebography; D013350:Subclavian Vein / Q000000981:diagnostic imaging; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000150:complications* / Q000000981:diagnostic imaging
keywords: Central venous occlusion; Inside-out central venous access; Laser; Pacemaker; Subclavian vein occlusion