Pacemaker and Defibrillator Lead Entrapment: Case Studies

Abstract

Cadavers and cineradiographic analysis have been used to document the effects of the medial subclavicular musculotendinous complex (MSMC) upon lead function. Four cadavers with pacemakers were dissected and photographed to demonstrate the course a lead takes as it passes through the costoclavicular region. One lead had been placed into the cephalic vein. In the other three cadavers, leads placed by currently accepted techniques of subclavian venipuncture were all found to pass through the soft tissues of the subclavicular region before entering the venous system. Cineradiographic results from a patient with a defibrillator, taken before and after replacement of a broken lead, show the effect of clavicular motion on a lead that passes through the MSMC. Furthermore, cineradiography makes it possible to identify the point where the lead entered the vein, and whether or not it escaped being caught up in the soft tissues of the MSMC.

Navigation by Parallax in Three‐Dimensional Space During Fluoroscopy: Application in Guide Wire‐Directed Axillary/Subclavian Vein Puncture

“…The axillary/subclavian vein is commonly used for transvenous lead placement and many different techniques have been developed for accessing it 1 . The axillary vein and the extrathoracic portion of the subclavian vein are preferable to the intra‐thoracic portion of the subclavian vein for this purpose in order to reduce the risk of “subclavian crush.” 2–5 A new technique for axillary/subclavian vein puncture based on the parallax principles was developed.…”

Upper Body Venous Access for Transvenous Lead Placement—Review of Existent Techniques

“…the subclavius and the costo‐clavicular ligament) (Fig. 1) than if they are intravascular and stay within the subclavian vein 3,4,57 . Entrapment within the medial subclavicular musculotendinous complex also subjects the leads to repeated flexion at the point of entrapment during shoulder movements.…”

“…In terms of advantages, the vein is comparatively large in caliber (and hence can comfortably accommodate multiple leads), usually readily accessible through venipuncture, and anatomically close to the preferred pulse generator site in the infraclavicular space. In terms of disadvantages, the vein is anatomically close to many vital structures at risk of accidental damage during venipuncture, and the medial subclavicular musculotendinous complex capable of damaging leads through compression and flexion 3,4,57 . To avoid subclavian crush, the axillary vein is preferable to the subclavian vein as the point of venous entry, but the subclavian vein is bigger in caliber, more constant in position anatomically, and generally easier to puncture.…”

Venous Access: Navigation in Three‐Dimensional Space

“…Electrode failure as a result of the extreme medial approach has been called the “crush phenomenon.” Fyke was the first to report insulation failure of two leads placed side by side in the percutaneous approach to the subclavian vein where there was a tight costoclavicular space 8,9 . There are a number of proposed mechanisms and potential solutions as proposed by Jacobs et al 10,11 and Magney et al 12 Electrodes of complex design, such as bipolar coaxial construction, are most susceptible to this phenomenon.…”