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Cardiology registrars and permanent pacemaker complication rates

Daniel M Sado, Wei Yao Lim and Martin Thomas
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DOI: https://doi.org/10.7861/clinmedicine.14-3-324
Clin Med June 2014
Daniel M Sado
AThe Heart Hospital, London, UK
Roles: StR in cardiology
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Wei Yao Lim
BThe Heart Hospital, London, UK
Roles: StR in cardiology
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Martin Thomas
CThe Heart Hospital, London, UK
Roles: Consultant in cardiology
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Editor – We read with interest the article by Leong et al exploring complication rates in the 12 weeks after pacemaker implantation in a UK district hospital (Clin Med February 2014 pp 34–7). We highlight a later complication that can occur and how to avoid it using a technique which will also be of interest to all physicians performing central venous access techniques.

In the Leong study the subclavian vein was the most frequent route utilised for venous access. As found in this study there is a small risk of pneumothorax. However, in the longer term it also conveys a small risk of a ‘crush’ injury to the pacemaker lead.1 This is thought to be a result of pressure exerted between the first rib and the clavicle on the lead just before it enters the vein. The first author of this letter has experience of this complication, resulting in transection (Fig 1a and b).

A different approach utilises the axillary vein (Fig 1c). As the puncture is extra-thoracic, there is no longer a risk of crush injury and the risk of pneumothorax is reduced. A number of methods allowing access to this vessel have been described. It can be identified using ultrasound (Fig 1d) with a number of papers describing ultrasound guided insertion with up to 100% success rates, short operator learning curves and low complication rates.2,3 Various fluoroscopic approaches have been described with very high success rates.4

We therefore believe that axillary venous access is safe, useful, easy to learn and therefore of use to all physicians performing central venous access techniques.

Fig 1.
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Fig 1.

(a) and (b) A crush injury a number of months following insertion of a right ventricular pacemaker lead. The lead is transected (arrow). (c) Venogram showing the basilic (BV), cephalic (CV), axillary (AxV) and subclavian (SV) veins. (d) Ultrasound taken at the level shown by the arrow showing the axillary artery (AxA) and vein. The venous nature of the vessel is confirmed using colour doppler and its compressibility under pressure applied to the probe.

Footnotes

  • Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk

  • © 2014 Royal College of Physicians

References

  1. ↵
    1. Gallik DM,
    2. Ben-Zur UM,
    3. Gross JN,
    4. Furman S
    . Lead fracture in cephalic versus subclavian approach with transvenous implantable cardioverter defibrillator systems. Pacing Clin Electrophysiol 1996;19:1089–94.doi:10.1111/j.1540-8159.1996.tb03418.x
    OpenUrlCrossRefPubMed
  2. ↵
    1. Sharma A,
    2. Bodenham AR,
    3. Mallick A
    . Ultrasound-guided infraclavicular axillary vein cannulation for central venous access. Br J Anaesth 2004;93:188–92.doi:10.1093/bja/aeh187
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Sommerkamp SK1,
    2. Romaniuk VM,
    3. Witting MD,
    4. et al.
    A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation. Am J Emerg Med 2013;31:478–81.doi:10.1016/j.ajem.2012.09.015
    OpenUrlCrossRefPubMed
  4. ↵
    1. Antonelli D,
    2. Feldman A,
    3. Freedberg NA,
    4. Turgeman Y
    . Axillary vein puncture without contrast venography for pacemaker and defibrillator leads implantation. Pacing Clin Electrophysiol 2013;36:1107–10.doi:10.1111/pace.12181
    OpenUrlCrossRefPubMed
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Cardiology registrars and permanent pacemaker complication rates
Daniel M Sado, Wei Yao Lim, Martin Thomas
Clinical Medicine Jun 2014, 14 (3) 324; DOI: 10.7861/clinmedicine.14-3-324

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Cardiology registrars and permanent pacemaker complication rates
Daniel M Sado, Wei Yao Lim, Martin Thomas
Clinical Medicine Jun 2014, 14 (3) 324; DOI: 10.7861/clinmedicine.14-3-324
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