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Procedure: Permanent biventricular defibrillator implants.
History: The patient received 1 gram
of IV vancomycin prophylactically before the procedure.
Procedure: Opportunity
for questions was provided and informed consent obtained. After
sterile preparation of the skin surrounding the left deltopectoral
area with antiseptic scrub this area was carefully covered with a
Steri-Drape followed by the application of sterile towels and a
sterile laparotomy sheet. Procedure was performed under general
anesthesia, delivered by staff anesthesiologist. Local anesthesia
with 1% lidocaine was administered an approximately 2-inch incision
across the left deltopectoral groove was made. Before the incision
was made, a nonselective venogram of the left upper extremity was
performed given the patient's history of breast cancer on that side,
we wanted to ensure that the venous anatomy is patent. Nonselective
venogram showed good patency of the left axillary, subclavian, as
well as cephalic vein. After the incision using blunt dissection
with careful hemostasis the left cephalic vein was isolated and
accessed between 2 silk ties. Two glide wires were inserted under
the guide of fluoroscopy and the left upper extremity venogram. The
left axillary access was also obtained and another guidewire was
inserted.
The patient was noted to have a venous stent from the right
subclavian vein encroaching onto the superior vena cava. However,
the nonselective venogram did not confirmed the stent coming all the
way to the superior vena cava.
The right ventricular lead that was implanted was a Boston
Scientific model , serial , that was advanced to the
left cephalic vein, and positioned in the RV apex and active
fixation mechanism deployed.
At this point, the right atrial lead which was a Guidant ,
serial# was advanced through the left cephalic vein and
brought to the level of the right atrium. With advancement of the
right atrial lead, there was some resistance underway, which was
concerning for possibility of the leads crossing this struts of the
of the venous stent that was coming from the right. At this point,
a 7-French sheath was introduced into the left axillary vein and a
selective venogram of the superior vena cava was performed, which
confirmed encroachment of the right-side of the stent all the way
into the superior vena cava. This proved that both leads had gone
through the straddled had gone through the struts of the stent
through the sidewalls of the stent crossing wall to wall before
coming back into the superior vena cava and at finding their way to
the right side of the heart. At this point, the decision was to
explant both leads given that the leads were crossing through the
walls of the of the stent and the patient would have been at risk
for superior vena cava syndrome as well as that face that this could
have compromised the stent and also the face that the mechanical
contact between the stent and the leads could have caused insulation
breach and unnecessary and inappropriate shocks in future.
Therefore, the active fixation mechanism was withdrawn again and RV
lead and the right atrial lead were both removed from the heart.
Proper hemostasis was achieved with 2-0 Vicryl sutures. Pocket was
irrigated with antibiotic solution and subcutaneous tissue closed
with interrupted absorbable suture and skin was closed with
continuous absorbable suture. Steri-Strips were applied and a
sterile occlusive dressing was applied on top of that. The patient
was transferred to monitoring area in stable condition.
Comments:
1. Attempt at CRT-D implant was aborted after selective venogram
confirmed that the right atrial and right ventricular leads
had crossed through the right subclavian vein, which had
encroached into the superior vena cava. Right-sided implant
is not suitable given the presence of an active AV fistula for
hemodialysis and history of prior complication with vascular
anatomy in the right upper extremity.
2. At this point, would recommend the options of either
subcutaneous ICD versus epicardial defibrillator and pacing
leads with the open thoracotomy. We will discuss the options
with the patient, and will proceed as the patient as per
patient's wishes.
Procedure: Permanent biventricular defibrillator implants.
History: The patient received 1 gram
of IV vancomycin prophylactically before the procedure.
Procedure: Opportunity
for questions was provided and informed consent obtained. After
sterile preparation of the skin surrounding the left deltopectoral
area with antiseptic scrub this area was carefully covered with a
Steri-Drape followed by the application of sterile towels and a
sterile laparotomy sheet. Procedure was performed under general
anesthesia, delivered by staff anesthesiologist. Local anesthesia
with 1% lidocaine was administered an approximately 2-inch incision
across the left deltopectoral groove was made. Before the incision
was made, a nonselective venogram of the left upper extremity was
performed given the patient's history of breast cancer on that side,
we wanted to ensure that the venous anatomy is patent. Nonselective
venogram showed good patency of the left axillary, subclavian, as
well as cephalic vein. After the incision using blunt dissection
with careful hemostasis the left cephalic vein was isolated and
accessed between 2 silk ties. Two glide wires were inserted under
the guide of fluoroscopy and the left upper extremity venogram. The
left axillary access was also obtained and another guidewire was
inserted.
The patient was noted to have a venous stent from the right
subclavian vein encroaching onto the superior vena cava. However,
the nonselective venogram did not confirmed the stent coming all the
way to the superior vena cava.
The right ventricular lead that was implanted was a Boston
Scientific model , serial , that was advanced to the
left cephalic vein, and positioned in the RV apex and active
fixation mechanism deployed.
At this point, the right atrial lead which was a Guidant ,
serial# was advanced through the left cephalic vein and
brought to the level of the right atrium. With advancement of the
right atrial lead, there was some resistance underway, which was
concerning for possibility of the leads crossing this struts of the
of the venous stent that was coming from the right. At this point,
a 7-French sheath was introduced into the left axillary vein and a
selective venogram of the superior vena cava was performed, which
confirmed encroachment of the right-side of the stent all the way
into the superior vena cava. This proved that both leads had gone
through the straddled had gone through the struts of the stent
through the sidewalls of the stent crossing wall to wall before
coming back into the superior vena cava and at finding their way to
the right side of the heart. At this point, the decision was to
explant both leads given that the leads were crossing through the
walls of the of the stent and the patient would have been at risk
for superior vena cava syndrome as well as that face that this could
have compromised the stent and also the face that the mechanical
contact between the stent and the leads could have caused insulation
breach and unnecessary and inappropriate shocks in future.
Therefore, the active fixation mechanism was withdrawn again and RV
lead and the right atrial lead were both removed from the heart.
Proper hemostasis was achieved with 2-0 Vicryl sutures. Pocket was
irrigated with antibiotic solution and subcutaneous tissue closed
with interrupted absorbable suture and skin was closed with
continuous absorbable suture. Steri-Strips were applied and a
sterile occlusive dressing was applied on top of that. The patient
was transferred to monitoring area in stable condition.
Comments:
1. Attempt at CRT-D implant was aborted after selective venogram
confirmed that the right atrial and right ventricular leads
had crossed through the right subclavian vein, which had
encroached into the superior vena cava. Right-sided implant
is not suitable given the presence of an active AV fistula for
hemodialysis and history of prior complication with vascular
anatomy in the right upper extremity.
2. At this point, would recommend the options of either
subcutaneous ICD versus epicardial defibrillator and pacing
leads with the open thoracotomy. We will discuss the options
with the patient, and will proceed as the patient as per
patient's wishes.