Pacemaker Implant Anatomy - Step-by-Step (Part 1)

Pacemaker Implant Anatomy – Step-by-Step (Part 1)

Approach

Pacemaker implantation can be performed either from the right side or from the left side (refer to Figure 1).
There is no difference in principle. It may depend on the patient’s preference.
The right sided approach demands a double curve.
The left sided approach allows for a unidirectional curve.

Figure 1: The Left Side and Right Side Approach

Figure 1: The Left Side and Right Side Approach

It depends on the preference of the implanting physician whether the cephalic cut down is used as the mode of entry, or the subclavian puncture technique.
Subclavian puncture as addressed here.
In anatomic drawings the course of the subclavian is fairly straight (Figure 2).

 

Figure 2: Anatomical Drawing of Subclavian Vein

Figure 2: Anatomical Drawing of Subclavian Vein


In real life, in the elderly patient the subclavian vein may flow in conjunction with a tortuous artery (Figure 3).

Figure 3: Subclavian Vein in Elderly Patient

Figure 3: Subclavian Vein in Elderly Patient

 

Once the choice for subclavian puncture has been made, the direction of puncture is important and should be made parallel to the clavicle (green line in Figure 4).

When a more medial introduction is selected, there is a risk of subclavian crush (red line in Figure 4).
Always allow for ample space between the clavicle and first rib in lead introduction.

Figure 4

Figure 4

 

The Incisura Jugularis and Acromion are reference points (see Figures 5 and 6).
On two thirds of the distance from the Acromion towards the Incisura Jugularis, the punture should be made.

Always allow for ample space between the clavicle and first rib in lead introduction. The direction and puncture under the clavicle is important to allow pacemaker leads sufficient freedom of movement.

When the puncture needle is directed too far upwards, the mandrin will slide into the internal jugular vein.

Figure 5

Figure 5

Figure 6

Figure 6

Fluoroscopy (see Figures 7 and 8) is helpful to find the proper direction for the mandrin.
First have a look at the proper position of the mandrin before sliding the introducer and sheath over it.

After the puncture a small incision is made just to allow the introducer access, thus avoiding opening a larger part of the skin for a prolonged time. In this way we can avoid infection to a certain extend. In another technique a larger incision is made prior to the subclavian puncture After the lead is introduced, the mandrin is re-introduced to serve as guiding for the second lead introduction. The mandrin is fixed during manipulation with of the first lead.

Figure 7

Figure 7

Figure 8

Figure 8

Cephalic Vein Approach

Some prefer the cephalic vein in entry in pacemaker implantation as this technique eliminates the risk of pneumothorax. Although at first this technique was thought to be only suitable for one lead systems but now with smaller French leads the cephalic vein does allow for the introduction of two leads.
Only for three lead systems this approach is not suitable as a single introduction site.
The cephalic vein is the extension of the most lateral vein in the ‘fossa cubitalis’. (Refer to Figures 9 to 12)

Figure 9: Anatomical diagram of the Cephalic Vein

Figure 9: Anatomical diagram of the Cephalic Vein

Figure 10: The Cephalic Vein approach

Figure 10: The Cephalic Vein approach

Figure 11: Anatomical cut-away diagram of the Cephalic Vein approach

Figure 11: Anatomical cut-away diagram of the Cephalic Vein approach

Figure 12: The smaller Cephalic Vein can be seen entering the larger Subclavian Vein

Figure 12: The smaller Cephalic Vein can be seen entering the larger Subclavian Vein

Continue to Part 2

Author:

Stuart Allen
Principal Cardiac Physiologist
Manchester Heart Centre
Manchester, UK

 

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