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The internal jugular vein as an alternative venous access for a revision of a fractured implantable cardioverter-defibrillator lead

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LETTER TO THE EDITOR

Copyright © 2017 The Korean Association of Internal Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/

by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

pISSN 1226-3303 eISSN 2005-6648 http://www.kjim.org Korean J Intern Med 2017;32:360-362

https://doi.org/10.3904/kjim.2015.221

1

Division of Cardiology, Department of Internal Medicine,

2

Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Daegu, Korea

The internal jugular vein as an alternative venous access for a revision of a fractured implantable cardioverter-defibrillator lead

Jong Yop Pae 1 , Yoon-Nyun Kim 1 , Min Young Do 1 , Hyoung-Seob Park 1 , Seongwook Han 1 , Seung-Ho Hur 1 , and Sae-Young Choi 2

Received : July 13, 2015 Revised : August 13, 2015 Accepted : August 18, 2015 Correspondence to Yoon-Nyun Kim, M.D.

Division of Cardiology,

Department of Internal Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea Tel: +82-53-250-7432 Fax: +82-53-250-7034 E-mail: ynkim@dsmc.or.kr

To the Editor,

The Sprint Fidelis Model 6949 lead is a transvenous high-voltage implantable cardioverter-defibrillator (ICD) lead made by Medtronic Inc. (Minneapolis, MN, USA). Medtronic issued a recall of its Fidelis lead in October 2007 because a 15% to 20% rate of lead-related com- plications was noted after almost 5 years of follow-up [1]. The most common cause of lead failure was a fracture of the pacing-sensing wire. When the lead fracture occurs, the ICD fails to deliver needed shocks or delivers repeated in- appropriate shocks. Therefore, patients who have Fidelis leads often experience an additional lead insertion or replace- ment.

Previous studies reported that after pacemaker or ICD implantations, a total or partial obstruction of the access vein rarely causes immediate clinical prob- lems. However, venous obstructions oc- cur relatively frequently and if the need for a lead revision or additional lead insertion arises, a different access route is required. Alternative methods have been studied, such as the utilization of other vessels or surgery [2,3]. We report a case in which the patient had both subclavian vein obstruction and under- went an additional pacing-sensing lead insertion through the internal jugular

vein (IJV) for a fractured Fidelis lead.

An 81-year-old woman presented

with an abnormal beeping sound from

her ICD. She had a history of a coro-

nary bypass surgery in 2002. The ICD

(Medtronic MAXIMO DR, Sprint Fidel-

is Model 6949) was implanted in 2006

due to sustained ventricular tachycar-

dia with loss of consciousness. She was

found to have a complete occlusion of

the left subclavian vein and the right

subclavian vein was chosen for the ICD

implantation. The ICD generator was

replaced 4 years ago using the same

Fidelis lead because the relatively high

risk of the extraction of the lead and her

old age were considered. She had been

doing well without any events while the

ICD was implanted. The patient had

heard a beeping sound from the ICD. A

device interrogation found a high im-

pedance of the Fidelis lead (2,660 ohms)

and many short V-V intervals with in-

appropriate shocks. We decided to add

an additional pacing-sensing lead but

a right subclavian vein occlusion with

collateral flow to the superior vena cava

was found on venography (Fig. 1). The

right IJV was selected as an alterna-

tive vascular access. Following asepsis

of the lateral cervical region and local

anesthesia, the IJV was punctured with-

out any difficulty between the sternal

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361 www.kjim.org Pae JY, et al. Alternative venous access for an ICD lead

https://doi.org/10.3904/kjim.2015.221

and clavicular belly of the sternocleidomastoid muscle (Fig. 2). An additional Sprint Qurattro Secure 6935 lead (Medtronic Inc.) was implanted in the right ventricle through a 9-Fr Peel-Away sheath. The lead was secured at the entry site. A subcutaneous tunnel was made from the entry site to the generator pocket through the anterior aspect of the clavicle. The additional lead was placed in the pocket through the subcutaneous tunnel (Fig. 3). The additional lead replaced the pacing-sensing part of the Fidelis lead and was connected to the pre-existing gen- erator. The incision was closed layer by layer. The patient was discharged 7 days after the procedure without any complications.

The Fidelis lead is a 6.6-Fr bipolar high-voltage lead that had become popular because of its ease of handling.

However, the Fidelis lead began to fracture soon after it was introduced in September 2004 and was withdrawn from the market in October 2007. The rate of Fidelis fail-

ures continues to increase over time. Hence, as time goes on, the necessity for a lead revision increases.

Obstruction of the access vein is a well-known com- plication of ICD implantations. Obstructions are most commonly asymptomatic and symptomatic cases are known infrequently [4]. The presence of an obstruction in the access vein can make follow-up procedures, either for lead revisions or implantations of additional leads, difficult. Mostly, the technique used for the lead implan- tation was a subclavian puncture or cephalic vein cut- down. Several methods have been used to avoid surgery and general anesthesia, such as venoplasty, dilatation of a chronic total venous occlusion, or femoral access [2,3].

Pires et al. [5] reported that the right IJV can be used as a safe access for placement of permanent electrodes in cases where a left vein access cannot be used or when a right vein access is technically difficult.

In our case, we present a patient with a fractured Fidel- is ICD lead and in which both subclavian veins were oc- Figure 1. Venogram showing the implanted lead and tight

stenosis of the right subclavian vein. Right internal jugular vein as an alternative vascular access (circle).

Figure 2. Chest radiograph showing the puncture of the right

internal jugular vein.

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362 www.kjim.org

The Korean Journal of Internal Medicine Vol. 32, No. 2, March 2017

https://doi.org/10.3904/kjim.2015.221

cluded. Due to inappropriate shocks owing to oversens- ing and high impedances, it was considered to be a lead fracture. Complications of lead revisions associated with extractions might be serious due to severe adhesions ob- served in venography and an additional lead implanta- tion was planned. The left subclavian vein had previous- ly been found to be occluded and in the venography, a right subclavian vein occlusion was also confirmed. We approached the right IJV as an alternative. We believed that the lead placement via the IJV with a subcutaneous tunnel to the subclavicular fossa could be an alternative

method for the cardiac device implantation in cases with a subclavian vein occlusion.

Keywords: Jugular veins; Defibrillators; Lead Conflict of interest

No potential conflict of interest relevant to this article was reported.

Acknowledgments

The research was supported by the Ministry of Science, ICT and Future Planning through the Development for IT·SW industrial convergence original technology (ID:

R0101-15-0147). We thank Mr. John Martin for his linguis- tic assistance.

REFERENCES

1. Birnie DH, Parkash R, Exner DV, et al. Clinical predic- tors of Fidelis lead failure: report from the Canadian Heart Rhythm Society Device Committee. Circulation 2012;125:1217-1225.

2. McCotter CJ, Angle JF, Prudente LA, et al. Placement of transvenous pacemaker and ICD leads across total chron- ic occlusions. Pacing Clin Electrophysiol 2005;28:921- 925.

3. Yousef Z, Paul V, Leyva F. Cardiac resynchronization via the femoral vein: a novel method in cases with contrain- dications to the pectoral approach. Europace 2006;8:144- 146.

4. Williams EH, Tyers GF, Shaffer CW. Symptomatic deep venous thrombosis of the arm associated with perma- nent transvenous pacing electrodes. Chest 1978;73:613- 615.

5. Pires LA, Hassan SA, Johnson KM. Coronary sinus lead placement via the internal jugular vein in patients with advanced heart failure: a simplified percutaneous ap- proach. J Interv Card Electrophysiol 2005;12:157-162.

Figure 3. Chest radiograph showing the implanted lead con-

figuration. Location of the puncture site of the right internal

jugular vein (circle).

수치

Figure 2. Chest radiograph showing the puncture of the right  internal jugular vein.
Figure 3. Chest radiograph showing the implanted lead con- con-figuration. Location of the puncture site of the right internal  jugular vein (circle).

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