Anatomical and Morphological Evaluation of Pacemaker Lead Compression

Abstract

In recent years, pacemaker lead failure due to compressive damage has been reported with increasing frequency. To document the mechanism of this failure, we evaluated explanted mechanically damaged leads with electrical testing, optical microscopy, and in some cases, scanning electron microscopy (SEM). In addition, we performed an autopsy study to measure the compressive loads on catheters placed percutaneously through the costoclavicular angle, as well as by cephalic cutdown. Of the 49 explanted compression damaged leads with enough clinical data for analysis, all had been placed by percutaneous subclavian puncture. Our autopsy data confirmed the significant increase in pressures generated in the costoclavicular angle for medial percutaneous subclavian catheterization (126 +/- 26 mmHg) compared to a more lateral percutaneous subclavian puncture (63 +/- 15 mmHg) or a cephalic cutdown (38 +/- 13 mmHg) (P < 0.01). In vivo coil compression testing documented loads up to 100 pounds per linear inch of coil and a compressive morphology by SEM identical to that seen in the clinical explants. Pacemaker leads appear to be susceptible to compression damage when placed by subclavian venipuncture. When possible, leads should be placed such that they avoid the tight costoclavicular angle.

Broken leads with proximal endings in the cardiovascular system: Serious consequences and extraction diffi culties

“…The PLE was anchored in the subclavian vein, 19 cases; in the innominate vein (12), in the right atrium (4), in the pulmonary artery (3), in the vena cava superior (2), in the jugular vein (2); in the right ventricle (2), and in the hepatic vein (1).…”

“…Active endocardial leads also may migrate to the CVS after their breakage. This may occur as a result of crush syndrome in case of an unfavorable position of a lead and the clavicle [2]. There also is a risk of lead fracture and later breakage at the site of ligature tightening on the lead at the venous entrance.…”

Radiology of cardiac devices and their complications

“…Fracture sites tend to occur at points of stress, such as between the clavicle and the first rib or the soft-tissue structures in this region. [25][26][27] For this reason, thoracic outlet syndrome has been anecdotally associated with lead fracture. 28 The tricuspid valve has also been described as a fracture site.…”

Axillary vein spasm during cardiac implantable electronic device implantation

“…The associated injury to the surrounding tissues as well as to the vein itself may induce reflex vascular spasm. In extreme situations this may lead to a complete occlusion of the venous lumen, which directly affects the course of the procedure, which may indirectly lead to later complications [9,13].…”

“…This is a result of the vessel's location between the clavicle and the first rib, which offers the mechanical conditions for thrombus formation [1]. As a result, cardiac lead placement via SV puncture may facilitate its mechanical damage over time [13].…”