Transvenous pacemaker insertion ipsilateral to chronic subclavian vein obstruction: An operative technique for children and adults

Subclavian vein occlusion limits insertion of pacing electrodes in children and adults. The concern is greatest in children with a long-term need for pacing systems necessitating use of the contralateral vein and potential bi lateral loss of access in the future. We describe an operative technique to provide ipsilateral access in chronic subclavian vein occlusion in five co nsecutive pediatric (n = 4, mean age 6.5 years) and adult (n = 1, age 70 wi th bilateral subclavian vein occlusion) patients in whom this condition was noted at the time of pacemaker or ICD implant. Occlusion was documented by venography. Pediatric cardiac diagnoses included complete heart block in a ll patients, tetralogy of Fallot in three, and I-transposition of the great vessels in one. Percutaneous brachiocephalic (innominate) or deep subclavi an venous access was achieved by a supraclavicular approach using an 18-gau ge Deseret angiocath, a Terumo Glidewire, and dilation to permit one or two 9-11 Fr sheaths. Electrode(s) were positioned in the heart and tunneled (p re- or retroclavicularly) to a! pre- or retropectoral pocket. Pacemaker and ICD implants were successful in all without any complication of pneumothor ax, arterial or nerve injury, or need for transfusion. Inadvertent arterial access did not occur as compared with prior infraclavicular attempts. Cme preclavicularly tunneled electrode dislodged with extreme exertion and was revised. Ipsilateral transvenous access for pacemaker or ICD is possible vi a a deep supraclavicular percutaneous approach when the subclavian venous o bstruction is discovered at the time of implant. in children, it avoids the use of the contralateral vein that may be needed for future pacing systems in adulthood. This venous approach provides access large enough to allow e ven dual chamber pacing in children and can be accomplished safely.