Device Implant Procedure

Preparation

Pre-procedure

Pre-procedure evaluation

• Check indication
• Decide on pacing mode
• Decide on side
• Discuss with patient

Pre-procedure preparation

• Fasting (hydration)
• Ipsilateral venous cannula
• Blood investigations
• Drugs - antiplatelets, anticoagulation
• Chest X-ray

Prep and drape

• Shaving / trimming
• Antiseptic scrub
• Drape
• Skin film

Anaesthesia and Instruments

Local anaesthesia

• Lignocaine
• Additional Bupivacaine
• 0.5 - 2.0 %
• 3-4 mg/kg

Anaesthesia

• Conscious sedation
• Fentanyl + Midazolam
• General anaesthesia

Instruments - 1

• Clamps - Hemostats, Allis, Babcock
• Scissors - Mayo, Metzenbaum
• Forceps - toothed, Adson

Instruments - 2

• Scalpel - #20 blade, #11/15 blade, #3 and #4 handle
• Needle holder
• Retractor - Senn, cats paw, Weitlaner self retaining

Incision and dissection

Choosing side

• Profession ?
• Left side - Common, easier route, problems with persistent LSVC
• Right side - Difficulty due to angulation, CRT difficult, ICD problems

Side

Persistent LSVC

Skin incision

• Horizontal
• Parallel to deltopectoral groove
• Length of incision
• 20 blade

Dissection

• Use self retaining retractor
• Sharp dissection with 11 blade / Cautery
• Upto Deltopectoral fascia

Venous access

Routes

• Cephalic vein
• Subclavian vein
• Axillary vein
• Other, unconventional

Venous access at JIPMER (approx)

• 75% - Cephalic vein (30% assisted)
• 24% - Axillary vein puncture (25% with venogram)
• 1% - Subclavian vein puncture

Anatomy

Cephalic vein

Cephalic vein dissection

• Sharp dissection of pectoral fascia
• Identify pad of fat in deltopectoral groove
• Vein is within pad of fat
• Separate from fascia, distal tie, open and pass lead

Cephalic vein dissection

Cephalic vein dissection

Assisted cephalic vein access

• Wire and lead
• Wire and peel-away
• 0.014 wire -> 5F -> exchange for 0.035 -> 7F

Cephalic vein

Cephalic vein

Cephalic venogram

Cephalic vein - pros and cons

• ( - ) Learning curve
• ( - ) Time
• ( - ) Painful
• ( - ) May not take multiple leads
• ( + ) No pneumothorax
• ( + ) No lead crush

Axillary vein

Axillary vein puncture

• Fluoro guided
• Junction of clavicle and first rib
• Walk along first rib

Axillary vein - pros and cons

• ( - ) Small learning curve
• ( - ) Needs fluoroscopy
• ( - ) Needs venogram (myth !)
• ( + ) Very low risk of pneumothorax
• ( + ) No lead crush

Subclavian vein

Subclavian vein puncture

Subclavian vein - pros and cons

• ( + ) More people are familiar
• ( + ) Anatomical landmarks sufficient
• ( - ) Risk of pneumothorax
• ( - ) Risk of lead crush

Lead crush

Single versus separate punctures

• In case of difficult punctures
• Routinely ?
• Retained guidewire technique
• Double wire technique

Tips

Axillary vein / subclavian puncture - tips

• Lignocaine in syringe
• No roll under shoulders
• Trendelenburg or elevate legs
• Verify venous access (IVC)

Avoiding air embolism

• Adequate hydration !
• Trendelenberg / Leg elevation
• Pinch sheath

Venogram

• Difficult puncture
• Pre-existing leads
• 10-15 ml of contrast from ipsilateral arm
• Management of stenosis

Puncture with venogram

Unconventional access

• Internal jugular vein
• Femoral vein

Lead placement

Ventricular lead placement

Choosing a lead

• Active or passive
• Length

RVA position - the mimics

• RA -> PFO -> LA -> LV
• RA -> CS -> lateral vein
• RA -> Hepatic vein

RVA placement

• Gently curved stylet
• Straight stylet
• RVOT -> RVA

RVA

RVA

RV apex

RVOT pacing

• Active fixation lead
• Stylet shaping

RVOT pacing

RVOT pacing

RVOT pacing

RVOT pacing

RVOT pacing

Extra loop

Atrial lead placement

Atrial appendage

• Pre-formed J
• J shaped stylet
• Recognize appendage position

Other atrial locations

• Active fixation lead
• Lateral wall
• Septum

VDD lead

VDD lead placement

• Similar to RVA lead
• Inter-electrode distance
• Position the bipole

Finishing

Fix and connect

Fixing lead

• Use a suture sleeve
• Fixing to fascia / muscle

Attaching PG

• Connector pin position
• Dynamometric wrench - stops and signals when desired torque is achieved
• Tug to test

Pocket

Pocket creation

• Sharp dissection
• Controlled blunt dissection
• Medial

Subpectoral pocket

• Indications
• Between heads of pectoralis major
• Split pectoralis major

Closure

Closure

• Subcutaneous- Vicryl 2-0 in two layers
• Skin - Vicryl 3-0 subcuticular
• Skin - Prolene 3-0 mattress

Post implant

Post implant care

Post procedure care

• Immobilisation / bed rest ?
• Analgesia
• Chest X ray after 4-6 hours

Post procedure care

• ECG / Pacemaker check
• Antibiotics ?
• Shower ?

Post procedure CXR

PG change

Preparation

• Check lead status if possible
• Check dependent status if possibletotal 2072
• Information about leads - uni/bi, connector type
• Need for pacing, need for upgrade / change

PG change

• Locating incision
• Avoid damage to lead

Venous stenosis

Venous obstruction