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ABSTRACT
We describe
a case of a pacemaker implantation via the femoral
vein in an octogenarian with obstructed superior
vena cava (SVC).
Key
Words:
Permanent pacemaker; Implantation; Femoral approach;
Aged, 80 and over; Supervior vena cava
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INTRODUCTION
In cases when implantation
of transvenous leads via the superior vena cava (SVC)
is not possible or contraindicated, the majority of
patients undergo thoracotomy and epicardial lead placement.
However, the surgical technique has its own inherent
risks and at times the patient's preference becomes
an issue. The safety and feasibility of permanent pacemakers
(PPM) via the fermoral approach has already been documented
in cases with difficulty or with contraindications to
the pectoral approach.(1-2) We report a permanent pacemaker
insertion via the femoral approach in an octogenarian,
which, to the best of our knowledge, is the first reported
case in the Middle East using this novel technique.
CASE
REPORT
Figure 1: ECG results
showing intermittent failure to capture
An 85-year-old woman was escorted
in a wheelchair by her family to the emergency department
on May 10, 2008 complaining of generalized weakness
and dizziness of one month duration. Her past medical
history included hypertension on Captopril 25 mg twice
daily, hypothyroidism on Levothyroxine 100 mcg once
daily and a dual chamber pacemaker implantation for
symptomatic atrioventricular (AV) block in January 2001.
After six months post implantation, the patient developed
facial and periorbital swelling, cough, dyspnea, hoarseness
of voice and had progressive decrease in her functional
level which was severe enough to make her dependent
in her daily activity. Due to the presence of other
medical conditions, the diagnosis of superior vena cava
syndrome (SVCS) was not taken into consideration during
her regular follow-up. On examination, the patient looked
puffy, weak and depressed. Her vital signs included
a heart rate of 36 beats per minute, blood pressure
of 124/50 mmHg, temperature of 36.5oC and a respiratory
rate of 16 breaths per minute and a score of 30/30 in
the mini mental exam. The rest of the examination was
unremarkable apart from dilated collateral veins in
the chest and upper arms. Her electrocardiogram (ECG)
showed intermittent failure to capture (Figure 1). Her
complete blood count, renal function test, liver function
and chest x-ray were unremarkable. TSH: 3.55mU/L (normal
range 0-27-4.20); FT4: 17.1 (normal range 12.0-22.0).
The device interrogation demonstrated that the device
reached an effective replacement indicator (ERI) with
high ventricular lead threshold.
Figure 2a: Right subclavian venogram demonstrating SVC
obstruction
Figure 2b: Delayed imaging of right subclavian venogram
showing collaterals through the azygous system
The patient was brought to the catheterization room
the same day, where her pacemaker was removed from the
left pectoral region under local anesthesia.Ventricular
lead had high threshold during testing, so the plan
was to introduce new leads. A venogram was done and
showed an occlusion at the junction between the SVC
and right atrium with good collaterals between the azygous
vein and the inferior vena cava (Figures 2a-2b). The
procedure was abandoned with a plan to proceed either
with an epicardial lead placement or a femoral approach.
While waiting for the arrival of the appropriate lead
(Medronics capture fix, Novus lead, 85 cm long), the
patient was kept on a temporary transvenous wire in
situ. She also underwent a CT angiography which confirmed
the absence of external compression and supported the
presence of thrombus so hypercoagulable state was investigated
and intravenous heparin was initiated thereafter. On
May 16, 2008, the patient underwent permanent pacemaker
implantation via the femoral approach.
The Femoral Approach
Under local anesthesia, an incision was made midway
between the right groin crease and inguinal ligament
centering on the femoral vein. The pocket was made cranial
to the incision. The ventricular lead was guided into
the femoral vein through a peel away sheath. The lead
was advanced to the right ventricle (RV) apex and secured
with active fixation. The proximal end of the lead was
connected to the pacemaker and then the device was implanted
in the pocket above the inguinal ligament (Figure 3).
After 24 hours of bed rest, the patient was discharged
home on broad spectrum antibiotics for one week and
warfarin to maintain the international normalization
ratio (INR) between 2-3. She was advised to resume normal
activity gradually within one week.
Figure 3: Permanent pacemaker position in the right
inguinal region
The patient has been followed biannually for two years.
There was tremendous improvement in her symptoms and
functional capacity as well as no evidence of procedure-related
complications ( thrombophlebitis, pocket infection or
lead dislodgement).
DISCUSSION
Our case demonstrates the
following important issues encountered while managing
this patient.
No upper age
limit for implanting permanent pacemaker via the femoral
approach
This approach was safe and effective in our elderly
patient. The under utilization of this simple and safe
approach may be due to the fear of complications of
the femoral approach. In the series of 27 patients reported
by Mathur et al (.1), there were no cases of thrombophlebitis,
thrombosis or embolism after 3 years of follow- up.
Only two possible cases of infection were reported.
Baraket et al.(2) also reported femoral pacemaker implantations
in 3 patients with no complications after a 6-month
follow-up. The major indication for this approach is
when endocardial pacing via the SVC is not possible
or contraindicated. SVC obstruction, as in our case
and in the majority of reported series was the main
reason. Scarring of the pectoral region due to previous
pocket infections or chest wall burns has also been
described. Another possible indication is in very thin
patients as well as in patients who have undergone post-mastectomy
and post-radiation therapy. A number of other cases
of successful cardiac resynchronization (CRT)(3) and
dual chamber implantable cardioverter defibrillator
(ICD) implantation through femoral approach have also
been reported.(4)
Under estimation
of clinically relevant symptom of SVC syndrome early
after permanent transvenous pacemaker implantation
Venous complications are usually asymptomatic and fortunately
symptomatic SVC syndrome is a rare complication after
transvenous pacemaker implantation. Goudevenous and
colleagues(5) reported that 1 out of 3100 and Bolad
et al(6) in their study (3 out of 3050) found patients
suffering from SVC syndrome after transvenous pacemaker
implantation. Multiple lead placement and previous infected
lead may increase the risk for SVC syndrome but are
not prerequisite. This complication may occur as early
as two days or as late as 15 years after implantation.
In those early presentations, acute thrombosis is believed
to be the cause and in chronic cases, fibrotic stenosis
has been supported by evidence found during surgery
and autopsy.(7)
The treatment modalities in this situation include anticoagulation,
thrombosis, endovascular treatment and surgery.(8,10)
In our case, the delayed diagnosis of SVC syndrome did
not result in severe complications that required major
surgical intervention due to the development of good
collaterals. In fact, our patient demonstrated dramatic
improvement post anticoagulation therapy. The successful
long term experience of conservative treatment has been
reported.(9) Also, anticoagulation is reasonable for
all patients with SVC syndrome caused by a pacemaker
as pulmonary embolism can occur and may be life-threatening.
Therefore, high degree of alertness and careful observation
of patients is necessary to initiate early treatment
which gives an acceptable success rate.(8)
Our case of femoral approach for pacemaker implantation
adds to the growing body of evidence that this approach
is safe and feasible in patients with contraindications
to the pectoral approach. This approach is safe not
only in younger patients but also in the geriatric group.
REFERENCES
1. Mathur G, Stables RH,
Heaven D, Ingram A, Sutton R. Permanent pacemaker implantation
via the femoral vein: an alternative in cases with contraindications
to the pectoral approach. Europace 2001; 3(1): 56-9.
2. Barakat K, Hill J, Kelly P. Permanent transfermoral
pacemaker implantation is the technique of choice for
patients in whom the superior vena cava is inaccessible.
Pacing Clin Electrophysiol 2000; 23(4 Pt.1): 446-9.
3. Yousef Z, Paul V, Leyva F. Cardiac resynchronization
via the femoral vein: a novel method in cases with contraindications
to the pectoral approach. Europace 2006; 8(2): 144-6.
4. Kler TS, Singh B, Gupta A, Bhargava K. Implantation
of dual chamber cardioverter-defibrillator through left
iliac vein in a patient with occluded superior vena
cava. Indian Heart J 2006; 58(6): 454-7.
5. Goudevenos JA, Reid PG, Adams PC, Holden MP, Williams
DO. Pacemaker-induced superior vena cava syndrome: report
of four cases and review of the literature. Pacing Clin
Electrophysiol 1989; 12(12):1890-5.
6. Bolad I, Karanam S, Mathew D, John R, Piemonte T,
Martin D. Percutaneous transvenous device implantation.
Catheter Cardiovasc Interv 2005; 65(1):54-9.
7. Kitamura J, Murakami Y, Shimada T et al. Morphological
observation by intravascular ultrasound in superior
vena cava syndrome after pacemaker implantation. Cathet
Cardiovasc Diagn 1996; 37(1):83-85.
8. Gray BH, Olin JW, Graor RA, Young JR, Bartholomew
JR, Ruschhaupt WF. Safety and efficacy of thrombolytic
therapy for superior vena cava syndrome. Chest 1991;
99(1):54-59.
9. Kataoka H. Ten-year follow-up of a patient with pacemaker
induced superior vena cava syndrome. Pacing Clin Electrophysiol
1997; 20(6):1734-1736.
10. Tan CW, Vitjitbenjarouk P, Khuri B. Superior vena
cava syndrome due to permanent tranvenous pacemaker
electrodes: succeesful treatment with combined thrombolysis
and angioplasty- a case report. Angioplasty 2000; 51(11):
963-969.
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