Safe Introducer Technique for Pacemaker Lead Implantation CHARLES L. BYRD From the University of Miami School of Medicine, Department of Surgery. Miami, Florida
BYRD, C. L.: Safe Introducer Technique for Pacemaker Lead Implantation. Over (he last several years, an introducer approach for pacemaker lead insertion has evolved that eliminates most introducer-related complications. The approach consists of defining a safe region for intrathoracic cannuiation of the subcJavian vein. If specific conditions cannot be met for entering the "safe" region or if the vein cannot be found, the subclavian vein is cannuJated extrathoracically. Recently, this technique was used in 263 consecutive patients undergoing pacemaker implantation. The infrathoracic portion of the subcJavian vein was used in 239 (90.9%) cases and the extrathoracic portion in 24 {9.1%}. One hundred and ninelyeight {75.3%} cases were right-sided and 65 (24.7%) were left-sided. On the right side, 177 (89.4%) used the intrathoracic portion of the subcJavian vein and 21 (10.6%) used the extrathoracic portion. On the left side, 62 (95.4%) used the intrathoracic portion and three (4.6%) used the extrathoracic. The introducer technique was successful in all cases and there were no introducer-related complications. (PACE, Vol. 15, March 1992) introducer, subciavian venipuncture, percutaneous venipuncture, venipuncture, pacemaker implantation
Introduction
Methods
The development of leads small enough to allow passage through an introducer was a major breakthrough for dual cfiamber pacing. It allowed easy access to the subclavian vein for passage of one or more leads.^'^ Introducer techniques, however, are not without inherent prohlems ranging from failure to find the vein to lethal vascular and pulmonary tears.'^"^ To date, the only obvious indicator of safety seems to be the experience of the operator. Experienced operators have fewer complications than inexperienced operators."^'^ This paper describes a step-by-step procedure for introducer insertion, either intrathoracically or extrathoracically, designed to eliminate most of the recognized complications including failure to find the vein.
The patient is placed in a supine position and the chest wall is examined. The right side is used except for an infection near the implant site, prominent chest wall veins suggesting a thrombosis of the subclavian or innominate vein, and patient preference for the left side. The right [or left) side of the neck and anterior chest wall are prepared and draped in a sterile fashion, leaving exposed an area extending from the anterior axillary line to the sternum. Local 1% lidocaine anesthesia is given as needed throughout the procedure. Fluoroscopy is used for all maneuvers (Fig. 1). An introducer with a 2h inch #18 gauge needle is used. For one lead, a 12 French introducer set is used; for two leads inserted simultaneously, a 14 French introducer set is used. The pacemaker pocket is constructed beneath a horizontal skin incision as shown in Figures 2 and 3, The incision is placed along a horizontal line located two finger breadths below the sternal notch. The lateral margin of the incision is a vertical line imagined through a point between the medial and lateral two thirds of the clavicle. The
Address for reprints: Charles L. Byrd, M.D., 945 Arthur Godfrey Road, Suite 202. Miami Beach, FL 33140. Fax: (305) 672-8179. Received March 20, 1991; revision September 11, 1991: revision November 20, 1991; accepted November 20, 1991.
262
March 1992
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SAFE INTRODUCER TECHNIQUE
Figure 1. Fluoroscopy is used to define Jandniarks necessary for needle insertion and is used Ihrougiiout the entire insertion procedure.
Figure 2. The enlrance into the intralhoracic safe region is bounded superiorly hy the clavicie and i'n/eriorly by the first rib. The medial and lateral borders of the entrance are determined by imagining a point in the center o/the neck and drawing a line from thai point through (he sternal notch. This is the 0° line, marking the medial boundary. The lateral boundary is a line drawn approximately 40° lateral to the 0° Hne. The posterior boundary cannot be reached by the arc traced bv the inserted 2h inch introducer needle. PACE, Vol. 15
March 1992
263
BYRD
Figure 3. For (he extrathoracic approach, the introducer needle is passed from the clavicle to an anterior portion on the first rib by a series of partial ivithdraivals and reinsertions. The needle is maneuvered posteriorly along the rib until (he vein is punctured. pacemaker pocket is constructed prior to insertion of the introducer. This introducer technique is separated into an intrathoracic and an extrathoracic approach. First, the boundaries are established for an intrathoracic safe region located in the thoracic inlet (Fig. 2). The introducer needle is passed to the clavicle near the entrance to the safe region, staying within the 40° arc. The condition for entering the safe region is based solely on the ease of passage of the introducer needle into the space between the clavicle and first rib. For entrance to the safe region, this space must be of sufficient size to accommodate the leads without binding or pinching. Placement of supports behind the shoulders to arch the back artificially enlarges the safe region and should not be used. If the entrance is not large enough or if attempts to puncture the subclavian vein witbin the safe region fail, the intrathoracic approach is abandoned, The extrathoracic approach is performed by maneuvering the introducer needle from the clavicle to the first rib by a series of partial withdrawals and reinsertions. The needle is advanced poste-
264
riorly along the rib until the vein is punctured (Fig. 3). Orientation is maintained by touching the rib with each maneuver. Once the vein is punctured using either the intrathoracic or extrathoracic approach, the guidewire (Fig. 4A] and introducer (Fig. 4B) are inserted. Approximately 90% of the venipunctures can be made from within the subcutaneous tissue pocket, using the intrathoracic approach.
Results Between January 1,1989, and January 1,1991, 263 consecutive patients had initial pacemaker implantations, all by the same surgeon, using the described safe introducer tecbnique. Relying on the concept of a safe region and the condition for entering this region, the introducer was inserted in the intrathoracic portion of the subclavian vein in 239 (90.9%) patients and in the extrathoracic portion in 24 (9.1%) patients. The incidence of extrathoracic insertions was less for the left side (4.6%) than for the right (10.6%J. However, due to the small number of left-sided procedures, no
March 1992
PACE, Vol. 15
SAFE INTRODUCER TECHNIQUE
Figure 4. (A) L/sing /luoroscopy, the guideivire is passed through the introducer needle into the right atrium. (Bj The tip of the inlroducer dilator is manually cun'ed slightly to facilitate passage in(o (he innominate vein. The advancement of the introducer dila(or and shealh is observed by /luoroscopy and (he free movement of the guidewire is tested.
interpretation can be given to this difference. The safe introducer technique was never abandoned, for failure to find the vein or for any other reason. In all 263 consecutive cases, a vein was successfully found and cannulated with no introducerrelated complications. Discussion Current introducer techniques for insertion of permanent transvenous pacemaker leads carry a small incidence of complications with varying severity.^"^^ In conventional techniques, the subclavian vein is punctured after the needle passes over the first rib into the thoracic inlet. In an attempt to eliminate most complications associated with this approach, we have defined conditions for an intrathoracic approach; a "safe region," the entrance to which must be of sufficient size to easily accommodate the leads. An extrathoracic approach was developed as an alternative to the intrathoracic approach. This nonconventional technique was designed to ensure cannuiation of the subclavian vein outside tbe safe region. The extrathoracic approach was
PACE, Vol. 15
used only for failure to enter the safe region or failure to locate the subclavian vein within the safe region. The success of the extrathoracic approach suggests its use as a primary approach. This hypothesis is currently being studied. The anatomy ot the intrathoracic and extrathoracic portions of the subclavian vein are determined by the first rib. The subclavian vein begins at the lateral border of the first rib. The medial border of this horizontally-oriented rib separates the subclavian vein into its intrathoracic and extrathoracic portions. Once the introducer needle passes the medial border of the first rib. the intrathoracic portion of the vein is punctured. The extrathoracic portion of the subclavian vein is punctured over the body of the first rib. The lateral border of the first rib serves as the boundary between the axillary and subclavian veins. An introducer tecbnique for cannulating the axillary vein lateral to the first rib has been reported." '^ Cannulations lateral to the rib are not part of this technique. To help illustrate the merits of this tecbnique, known introducer related complications compiled from the literature are separated into patient and
March 1992
265
BYRD
Table I. Patient Related Complications Complication
Clinical Outcome
Failure to find vein Lung puncture Subclavian artery tear Brachial plexus damage Esophagus and/or trachea puncture Transpulmonary cannuiation of the innominate vein Innominate and/or Azygos vein tear
Venotomy or opposite side" Pneumothorax Hemorrhage Pain and/or paresthesias* Infection Pneumothorax, Hemorrhage, and/or Infection Hemorrhage
' Except for failure to cannulate the subclavian vein or damage to the brachial plexus, the clinical problems are potentially life-threatening.
lead related complications (Tables I and 11].^-^ Failure to cannulate the intrathoracic portion of tbe subclavian vein is probably the most common patient related introducer complication. For example, variations in the chest wall configuration may cause an inadequately sized entrance to the safe region, posterior routing of the subclavian vein behind the safe region, or an angle into the innominate vein that is too acute. '•' Combining the intrathoracic and extrathoracic approaches ensures cannulating the vein. Lateral motions of an introducer needle tip
Table II.
beneath the chest wall musculature may tear an artery, vein, or nerve. The needle should be withdrawn into the musculature before moving the tip in any direction other than along its longitudinal axis. Consequently, probing only in tbe direction of the longitudinal axis of tbe needle sbould eliminate those needle related complications. Confining needle probes to the safe region and to the extrathoracic portion of the first rib also prevents punctures of the lung, esophagus, trachea, and transpulmonary cannuiation of the innominate vein. For some, there may be psychological barriers to be overcome in passing a needle directed towards the first rib. especially in combination with poor visualization of the first rib by fluoroscopy. The psychological barrier and poor visualization of the first rib are readily overcome by experience and adequate fluoroscopy, respectively. Lead related introducer complications are mechanically induced device failures caused by excessive stress applied to the lead during insertion through the introducer, by wedging the lead between the clavicle and first rib, or by routing tbe lead through tendon or bone. Forcing ieads through an introducer constricted by an acute bend in the vasculature may damage the electrode, fixation device, and insultion. If the entrance to the safe region is too small, leads may be pinched between the clavicle and first rib, causing insulation failure and fracture of tbe conductor coil. Passing leads through hone or tendon entraps the flexible lead body in a rigid structure, another potential cause of insulation failure and conductor coil fracture.^" Using the extrathoracic approach when the entrance to the intrathoracic safe region is too small prevents all of these lead-related introducer complications.
Lead Related Complications Complication
Forcing lead through the introducer Binding of leads between clavicle and first rib Periosteum and/or tendon puncture
266
Damage to Lead
Conclusion
Electrode, fixation device or insulation damage Insulation Compression fracture Polyurethane degradation Conductor coil fracture Polyurethane degradation Conductor coii fracture
Historically, the potential complications associated with intrathoracic cannuiation of the subclavian vein have been a deterrent to its use. In an attempt to eliminate most patient- and lead-related complications, an intrathoracic safe region and the conditions for entering this region were defined. In addition, an alternative extrathoracic approach was developed, applicable to all patients, and used upon failure to enter or cannulate the vein
March 1992
PACE. Vol. 15
SAFE INTRODUCER TECHNIQUE
within the safe region. To date, the intrathoracic approach was used in 90% of our patient population and the extrathoracic approach in approximately 10%. The safe introducer technique was
successfully applied to all patients and seems capable of eliminating most introducer related complications in an efficacious manner.
References 1. Littleford PO. Physiologic temporary pacing: Techniques and indications. In Barold SS (ed.): Modern Cardiac Pacing. Mount Kisco, NY. Futura Publishing Company. Inc.. 1985. pp. 231-255. 2. Bognolo DA. Recent advances in permanent pacemaker implantation techniques. In Barold SS (ed.): Modern Cardiac Pacing. Mount Kisco. NY, Futura Publishing Company, Inc., 1985, pp. 199-229. 3. Parsonnet V. Bernstein AD, Lindsay B. Pacemaker implantation complication rates: An analysis of some contributing factors.) Am Coll Cardiol 1989: 13(4):917-921. 4. Furman S. Venous cutdown for pacemaker implantation. Ann Thorac Surg 1986: 41:438-439. 5. Parsonnet V, Bernstein AD. Cardiac Pacing in the 198O's: Treatment and techniques in transition. } Am Coll Cardiot 1983; l(l):339-354. 6. Holmes DR, Hayes DL. Furman S. Permanent pacemaker implantation. In A Practice of Cardiac Pacing. 2nd revision. Mount Kisco, NY, Futura Publishing Company, Inc., 1989, pp. 239-287. 7. Hayes DL. Pacemaker implantation, permanent and temporary. In Holmes DR, Vlietstra RE [eds.): Interventional Cardiology. Philadelphia, PA, F.A. Davis, 1989: pp. 233-265. 8. Parsonnet V. Techniques for permanent transve-
PACE, Vol. 15
9.
10.
11. 12. 13.
14.
March 1992
nous pacemaker implantation: Personal preferences. In World Symposium on Cardiac Pacing, 7th, Vienna, 1983. Cardiac Pacing: Proceedings. Darmstadt, Federal Republic of Cermany, Steinkopff Verlag, 1983, pp. 441-448. Belott PH. Implantation techniques: New developments. In Barold SS, Mugica } (eds.): New Perspectives in Cardiac Pacing. Mount Kisco, NY, Futura Publishing Company, Inc. 1988, pp. 255-277. Smyth NPD, Millette ML. Complications of pacemaker implantation. In Barold SS (ed.): Modern Cardiac Pacing. Mount Kisco, NY, Futura Publishing Company, Inc., 1985, pp. 257-304. Nichalls RWD. A new percutaneous infraclavicular approach to the axillary vein. Anesthesia 1987; 42:151-154. Taylor BL, Yellowlees I, Central venous cannuiation using the infraclaviuular axillary vein. Anesthesiology 1990: 72(l):55-58. Byrd CL. Implantation procedures. In Zipes DP (ed.): Current Clinical Applications of Dual-Chamber Pacing. Minneapolis, MN, Medtronic, Inc., 1982, pp. 70-85. Subclavian puncture may result in lead conductor fracture. Medtronic News Winter. Minneapolis, MN, Medtronic, Inc., 1986/1987, p. 27.
267
BYRD, C. L.: Safe Introducer Technique for Pacemaker Lead Implantation. Over (he last several years, an introducer approach for pacemaker lead insertion has evolved that eliminates most introducer-related complications. The approach consists of defining a safe region for intrathoracic cannuiation of the subcJavian vein. If specific conditions cannot be met for entering the "safe" region or if the vein cannot be found, the subclavian vein is cannuJated extrathoracically. Recently, this technique was used in 263 consecutive patients undergoing pacemaker implantation. The infrathoracic portion of the subcJavian vein was used in 239 (90.9%) cases and the extrathoracic portion in 24 {9.1%}. One hundred and ninelyeight {75.3%} cases were right-sided and 65 (24.7%) were left-sided. On the right side, 177 (89.4%) used the intrathoracic portion of the subcJavian vein and 21 (10.6%) used the extrathoracic portion. On the left side, 62 (95.4%) used the intrathoracic portion and three (4.6%) used the extrathoracic. The introducer technique was successful in all cases and there were no introducer-related complications. (PACE, Vol. 15, March 1992) introducer, subciavian venipuncture, percutaneous venipuncture, venipuncture, pacemaker implantation
Introduction
Methods
The development of leads small enough to allow passage through an introducer was a major breakthrough for dual cfiamber pacing. It allowed easy access to the subclavian vein for passage of one or more leads.^'^ Introducer techniques, however, are not without inherent prohlems ranging from failure to find the vein to lethal vascular and pulmonary tears.'^"^ To date, the only obvious indicator of safety seems to be the experience of the operator. Experienced operators have fewer complications than inexperienced operators."^'^ This paper describes a step-by-step procedure for introducer insertion, either intrathoracically or extrathoracically, designed to eliminate most of the recognized complications including failure to find the vein.
The patient is placed in a supine position and the chest wall is examined. The right side is used except for an infection near the implant site, prominent chest wall veins suggesting a thrombosis of the subclavian or innominate vein, and patient preference for the left side. The right [or left) side of the neck and anterior chest wall are prepared and draped in a sterile fashion, leaving exposed an area extending from the anterior axillary line to the sternum. Local 1% lidocaine anesthesia is given as needed throughout the procedure. Fluoroscopy is used for all maneuvers (Fig. 1). An introducer with a 2h inch #18 gauge needle is used. For one lead, a 12 French introducer set is used; for two leads inserted simultaneously, a 14 French introducer set is used. The pacemaker pocket is constructed beneath a horizontal skin incision as shown in Figures 2 and 3, The incision is placed along a horizontal line located two finger breadths below the sternal notch. The lateral margin of the incision is a vertical line imagined through a point between the medial and lateral two thirds of the clavicle. The
Address for reprints: Charles L. Byrd, M.D., 945 Arthur Godfrey Road, Suite 202. Miami Beach, FL 33140. Fax: (305) 672-8179. Received March 20, 1991; revision September 11, 1991: revision November 20, 1991; accepted November 20, 1991.
262
March 1992
PACE, Vol. 15
SAFE INTRODUCER TECHNIQUE
Figure 1. Fluoroscopy is used to define Jandniarks necessary for needle insertion and is used Ihrougiiout the entire insertion procedure.
Figure 2. The enlrance into the intralhoracic safe region is bounded superiorly hy the clavicie and i'n/eriorly by the first rib. The medial and lateral borders of the entrance are determined by imagining a point in the center o/the neck and drawing a line from thai point through (he sternal notch. This is the 0° line, marking the medial boundary. The lateral boundary is a line drawn approximately 40° lateral to the 0° Hne. The posterior boundary cannot be reached by the arc traced bv the inserted 2h inch introducer needle. PACE, Vol. 15
March 1992
263
BYRD
Figure 3. For (he extrathoracic approach, the introducer needle is passed from the clavicle to an anterior portion on the first rib by a series of partial ivithdraivals and reinsertions. The needle is maneuvered posteriorly along the rib until (he vein is punctured. pacemaker pocket is constructed prior to insertion of the introducer. This introducer technique is separated into an intrathoracic and an extrathoracic approach. First, the boundaries are established for an intrathoracic safe region located in the thoracic inlet (Fig. 2). The introducer needle is passed to the clavicle near the entrance to the safe region, staying within the 40° arc. The condition for entering the safe region is based solely on the ease of passage of the introducer needle into the space between the clavicle and first rib. For entrance to the safe region, this space must be of sufficient size to accommodate the leads without binding or pinching. Placement of supports behind the shoulders to arch the back artificially enlarges the safe region and should not be used. If the entrance is not large enough or if attempts to puncture the subclavian vein witbin the safe region fail, the intrathoracic approach is abandoned, The extrathoracic approach is performed by maneuvering the introducer needle from the clavicle to the first rib by a series of partial withdrawals and reinsertions. The needle is advanced poste-
264
riorly along the rib until the vein is punctured (Fig. 3). Orientation is maintained by touching the rib with each maneuver. Once the vein is punctured using either the intrathoracic or extrathoracic approach, the guidewire (Fig. 4A] and introducer (Fig. 4B) are inserted. Approximately 90% of the venipunctures can be made from within the subcutaneous tissue pocket, using the intrathoracic approach.
Results Between January 1,1989, and January 1,1991, 263 consecutive patients had initial pacemaker implantations, all by the same surgeon, using the described safe introducer tecbnique. Relying on the concept of a safe region and the condition for entering this region, the introducer was inserted in the intrathoracic portion of the subclavian vein in 239 (90.9%) patients and in the extrathoracic portion in 24 (9.1%) patients. The incidence of extrathoracic insertions was less for the left side (4.6%) than for the right (10.6%J. However, due to the small number of left-sided procedures, no
March 1992
PACE, Vol. 15
SAFE INTRODUCER TECHNIQUE
Figure 4. (A) L/sing /luoroscopy, the guideivire is passed through the introducer needle into the right atrium. (Bj The tip of the inlroducer dilator is manually cun'ed slightly to facilitate passage in(o (he innominate vein. The advancement of the introducer dila(or and shealh is observed by /luoroscopy and (he free movement of the guidewire is tested.
interpretation can be given to this difference. The safe introducer technique was never abandoned, for failure to find the vein or for any other reason. In all 263 consecutive cases, a vein was successfully found and cannulated with no introducerrelated complications. Discussion Current introducer techniques for insertion of permanent transvenous pacemaker leads carry a small incidence of complications with varying severity.^"^^ In conventional techniques, the subclavian vein is punctured after the needle passes over the first rib into the thoracic inlet. In an attempt to eliminate most complications associated with this approach, we have defined conditions for an intrathoracic approach; a "safe region," the entrance to which must be of sufficient size to easily accommodate the leads. An extrathoracic approach was developed as an alternative to the intrathoracic approach. This nonconventional technique was designed to ensure cannuiation of the subclavian vein outside tbe safe region. The extrathoracic approach was
PACE, Vol. 15
used only for failure to enter the safe region or failure to locate the subclavian vein within the safe region. The success of the extrathoracic approach suggests its use as a primary approach. This hypothesis is currently being studied. The anatomy ot the intrathoracic and extrathoracic portions of the subclavian vein are determined by the first rib. The subclavian vein begins at the lateral border of the first rib. The medial border of this horizontally-oriented rib separates the subclavian vein into its intrathoracic and extrathoracic portions. Once the introducer needle passes the medial border of the first rib. the intrathoracic portion of the vein is punctured. The extrathoracic portion of the subclavian vein is punctured over the body of the first rib. The lateral border of the first rib serves as the boundary between the axillary and subclavian veins. An introducer tecbnique for cannulating the axillary vein lateral to the first rib has been reported." '^ Cannulations lateral to the rib are not part of this technique. To help illustrate the merits of this tecbnique, known introducer related complications compiled from the literature are separated into patient and
March 1992
265
BYRD
Table I. Patient Related Complications Complication
Clinical Outcome
Failure to find vein Lung puncture Subclavian artery tear Brachial plexus damage Esophagus and/or trachea puncture Transpulmonary cannuiation of the innominate vein Innominate and/or Azygos vein tear
Venotomy or opposite side" Pneumothorax Hemorrhage Pain and/or paresthesias* Infection Pneumothorax, Hemorrhage, and/or Infection Hemorrhage
' Except for failure to cannulate the subclavian vein or damage to the brachial plexus, the clinical problems are potentially life-threatening.
lead related complications (Tables I and 11].^-^ Failure to cannulate the intrathoracic portion of tbe subclavian vein is probably the most common patient related introducer complication. For example, variations in the chest wall configuration may cause an inadequately sized entrance to the safe region, posterior routing of the subclavian vein behind the safe region, or an angle into the innominate vein that is too acute. '•' Combining the intrathoracic and extrathoracic approaches ensures cannulating the vein. Lateral motions of an introducer needle tip
Table II.
beneath the chest wall musculature may tear an artery, vein, or nerve. The needle should be withdrawn into the musculature before moving the tip in any direction other than along its longitudinal axis. Consequently, probing only in tbe direction of the longitudinal axis of tbe needle sbould eliminate those needle related complications. Confining needle probes to the safe region and to the extrathoracic portion of the first rib also prevents punctures of the lung, esophagus, trachea, and transpulmonary cannuiation of the innominate vein. For some, there may be psychological barriers to be overcome in passing a needle directed towards the first rib. especially in combination with poor visualization of the first rib by fluoroscopy. The psychological barrier and poor visualization of the first rib are readily overcome by experience and adequate fluoroscopy, respectively. Lead related introducer complications are mechanically induced device failures caused by excessive stress applied to the lead during insertion through the introducer, by wedging the lead between the clavicle and first rib, or by routing tbe lead through tendon or bone. Forcing ieads through an introducer constricted by an acute bend in the vasculature may damage the electrode, fixation device, and insultion. If the entrance to the safe region is too small, leads may be pinched between the clavicle and first rib, causing insulation failure and fracture of tbe conductor coil. Passing leads through hone or tendon entraps the flexible lead body in a rigid structure, another potential cause of insulation failure and conductor coil fracture.^" Using the extrathoracic approach when the entrance to the intrathoracic safe region is too small prevents all of these lead-related introducer complications.
Lead Related Complications Complication
Forcing lead through the introducer Binding of leads between clavicle and first rib Periosteum and/or tendon puncture
266
Damage to Lead
Conclusion
Electrode, fixation device or insulation damage Insulation Compression fracture Polyurethane degradation Conductor coil fracture Polyurethane degradation Conductor coii fracture
Historically, the potential complications associated with intrathoracic cannuiation of the subclavian vein have been a deterrent to its use. In an attempt to eliminate most patient- and lead-related complications, an intrathoracic safe region and the conditions for entering this region were defined. In addition, an alternative extrathoracic approach was developed, applicable to all patients, and used upon failure to enter or cannulate the vein
March 1992
PACE. Vol. 15
SAFE INTRODUCER TECHNIQUE
within the safe region. To date, the intrathoracic approach was used in 90% of our patient population and the extrathoracic approach in approximately 10%. The safe introducer technique was
successfully applied to all patients and seems capable of eliminating most introducer related complications in an efficacious manner.
References 1. Littleford PO. Physiologic temporary pacing: Techniques and indications. In Barold SS (ed.): Modern Cardiac Pacing. Mount Kisco, NY. Futura Publishing Company. Inc.. 1985. pp. 231-255. 2. Bognolo DA. Recent advances in permanent pacemaker implantation techniques. In Barold SS (ed.): Modern Cardiac Pacing. Mount Kisco. NY, Futura Publishing Company, Inc., 1985, pp. 199-229. 3. Parsonnet V. Bernstein AD, Lindsay B. Pacemaker implantation complication rates: An analysis of some contributing factors.) Am Coll Cardiol 1989: 13(4):917-921. 4. Furman S. Venous cutdown for pacemaker implantation. Ann Thorac Surg 1986: 41:438-439. 5. Parsonnet V, Bernstein AD. Cardiac Pacing in the 198O's: Treatment and techniques in transition. } Am Coll Cardiot 1983; l(l):339-354. 6. Holmes DR, Hayes DL. Furman S. Permanent pacemaker implantation. In A Practice of Cardiac Pacing. 2nd revision. Mount Kisco, NY, Futura Publishing Company, Inc., 1989, pp. 239-287. 7. Hayes DL. Pacemaker implantation, permanent and temporary. In Holmes DR, Vlietstra RE [eds.): Interventional Cardiology. Philadelphia, PA, F.A. Davis, 1989: pp. 233-265. 8. Parsonnet V. Techniques for permanent transve-
PACE, Vol. 15
9.
10.
11. 12. 13.
14.
March 1992
nous pacemaker implantation: Personal preferences. In World Symposium on Cardiac Pacing, 7th, Vienna, 1983. Cardiac Pacing: Proceedings. Darmstadt, Federal Republic of Cermany, Steinkopff Verlag, 1983, pp. 441-448. Belott PH. Implantation techniques: New developments. In Barold SS, Mugica } (eds.): New Perspectives in Cardiac Pacing. Mount Kisco, NY, Futura Publishing Company, Inc. 1988, pp. 255-277. Smyth NPD, Millette ML. Complications of pacemaker implantation. In Barold SS (ed.): Modern Cardiac Pacing. Mount Kisco, NY, Futura Publishing Company, Inc., 1985, pp. 257-304. Nichalls RWD. A new percutaneous infraclavicular approach to the axillary vein. Anesthesia 1987; 42:151-154. Taylor BL, Yellowlees I, Central venous cannuiation using the infraclaviuular axillary vein. Anesthesiology 1990: 72(l):55-58. Byrd CL. Implantation procedures. In Zipes DP (ed.): Current Clinical Applications of Dual-Chamber Pacing. Minneapolis, MN, Medtronic, Inc., 1982, pp. 70-85. Subclavian puncture may result in lead conductor fracture. Medtronic News Winter. Minneapolis, MN, Medtronic, Inc., 1986/1987, p. 27.
267
