Dm. Gallik et al., LEAD FRACTURE IN CEPHALIC VERSUS SUBCLAVIAN APPROACH WITH TRANSVENOUSIMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEMS, PACE, 19(7), 1996, pp. 1089-1094
Lead fracture, occurring in approximately 1%-4% of patients, is an inf
requent, but potentially catastrophic complication of permanent pacing
systems. Its incidence in transvenous defibrillator systems has not b
een established. We analyzed data from 757 patients undergoing implant
ation of transvenous cardioverter defibrillator systems using the Medt
ronic Transvene Lead(R) system between October 20, 1989 and June 25, 1
992 to determine if site of venous approach influenced incidence of le
ad fracture. All patients received a 3-lead system in 1 of 3 configura
tions: (1) right ventricle/superior vena cava/subcutaneous patch; (2)
right ventricle/coronary sinus/subcutaneous patch; or (3) right ventri
cle/superior vena cava/coronary sinus. Of 767 right ventricular leads
placed, 523 were placed via the subclavian vein, 221 via cephalic vein
, and 18 via the infernal jugular (5 leads were implanted using anothe
r vein). The total number of leads is greater than the total number of
patients, as five patients received a second defibrillator system if
the initial system was explanted and reimplanted for any reason. Seven
patients (0.9%) had right ventricular lead fracture, presenting with
inappropriate defibrillator shocks (1), loss of pacing ability (3), bo
th loss of pacing ability and inappropriate shocks (1), or increased p
acing threshold (2). All patients required reoperation. All had leads
placed by the subclavian venous approach, with chest X ray confirming
fracture at the clavicle-first rib junction in 6 of 7 cases. Using Fis
her's Exact test, the difference in lead fracture between subclavian a
nd cephalic vein implant approached statistical significance (P = 0.08
). The trend toward increased lead fracture incidence with leads place
d via subclavian vein suggests that cephalic vein approach may be pref
erable to avoid this complication.