Punktion der Vena subclavia als primärer Zugang bei der Schrittmacher-Sondenimplantation

Abstract

In the beginning of transvenous pacemaker therapy, the external or alternatively internal jugular vein was commonly used for lead implantation. Due to frequent long-term complications both approaches are nowadays obsolete. In most pacemaker centers implantation via the cephalic vein has become standard. As an alternative, in 1975 Sterz et al. introduced puncture of the subclavian vein in the Seldinger technique as an approach for lead implantation. At this time, the commonly used introducers of pacemaker leads had to be cut for removal. No earlier than 1980 "peel away" introducers were commercially available. Since then, we consequently use this technique for implantation of single or dual chamber pacemaker devices. In the course of the last seven years merely 1.5-2% of implantations were performed via the cephalic vein; no jugular vein approach was performed. Due to a routinely performed subclavian vein puncture, we were able to optimize the procedure, proven by an enormous reduction in implantation time (local anesthesia - skin closure), x-ray time and complication rate. In the year 2000 we performed 52 implantations of a single chamber device with an average fluoroscopy time of 1.5 (0.3-9.3) minutes, radiation dose of 4.5 (0.1-47) Gycm(2) and implantation time of 17.6 (8-40) minutes and 144 implantations of a dual chamber device with an average fluoroscopy time of 2.86 (0.7-6.6) minutes, radiation dose of 8.31 (0.7-28) Gycm(2) and implantation time of 21.25 (10-45) minutes. Complications were rare, clinically irrelevant arterial punctures. Neither nerval damage nor pneumothoraces with the necessity for chest tube placement were seen in the above mentioned time frame. No early or late thrombosis of the subclavian vein was encountered. The primary subclavian vein approach led to an enormous reduction in overall procedure time without significant morbidity.

Influence of implantation access on complication rates in pacemaker implantation: An analysis of quality insurance data

“…We can thus agree with the publication by Eberhard, et al which describes an extendet interventionand luoroscopy time after subclavian puncture [23]. Other studies describe a longer implantation time with access via VC [4,5,24].…”

“…The results are consistent with those of several other smaller studies in which VS was preferred [3,4,8,12]. Regarding the generally higher implantation rate via VS access, the annual report of the German pacemaker and de ibrillator register even speaks of a "trend towards the wrong right" [13].…”

“…In previous studies it has been described that the VC is often only suitable for the implantation of single-chamber systems due to its small size [4,5]. In contrast to this in our analyzed population all systems could be successfully implanted via both accesses.…”

“…In Germany, more implantations are performed via VS than via VC [2]. Reasons are the reported higher success rate, the shorter operation and luoroscopy times, lower blood loss and the simple puncture of the vein [3][4][5][6][7]. Additionally, the access via VS is associated with a higher rate of pneumothorax [6,7].…”