Cardiac Rhythm Management
Articles Articles 2010 December

Transiliac Biventricular ICD Implantation: The Next Step in Patients with Upper Extremity Venous Occlusion

DOI: 10.19102/icrm.2010.011208

1RAKESH GOPINATHANNAIR, MD, MA, 2DWAYNE N. CAMPBELL, MD, 2GARY GOLDSMITH, RTR, RCIS and 2BRIAN OLSHANSKY, MD, FHRS

1 Division of Cardiovascular Medicine, University of Louisville, Louisville, KY
2 Division of Cardiovascular Medicine, University of Iowa Hospitals, Iowa City, IA

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The authors report no conflicts of interest for the published content.
Manuscript received October 18, 2010, final version accepted October 27, 2010.

Address correspondence to: Rakesh Gopinathannair MD, MA, Assistant Professor of Medicine, Division of Cardiovascular Medicine, University of Louisville Hospitals, ACB/A3L42, 550 South Jackson St., Louisville, KY 40202. E-mail: r0gopi01@gwise.louisville.edu

Patients needing cardiac resynchronization therapy defibrillator (CRT-D) support but have no suitable upper extremity venous access bilaterally present a difficult problem. We present a 78-year-old pacemaker-dependent man with a right subclavian CRT-D for standard indications who later developed pocket erosion and infected hardware. A temporary pacemaker was placed after lead extraction and device removal. Left upper extremity venography showed complete occlusion of left subclavian and internal jugular veins precluding a left-sided CRT-D implant (Figure 1). Given the right-sided pocket infection and the desire to avoid an epicardial system, an iliac approach for CRT-D implant was attempted. Under ultrasound guidance, the left external iliac vein was accessed 1 cm above the inguinal ligament to place right atrial (60 cm DEXTRUS, Boston Scientific, Natick, MA), dual-coil right ventricular (90 cm RELIANCE, Boston Scientific), and coronary sinus (100 cm EASYTRAK 2, Boston Scientific) leads (Figure 2). A 57 cm RAPIDO outer sheath (Boston Scientific) facilitated coronary sinus lead placement. Leads were anchored to the fascia at the venous access site, tunneled to a pocket in the left upper abdominal quadrant, and connected to a high-energy (41 J) device (Boston Scientific COGNIS). A CT scan image demonstrating the location of the device and the course of the leads is shown in Figure 3. Defibrillation threshold testing showed an adequate safety margin of >10 J. At 14-month follow-up, the patient continues to do well with CRT pacing and without any lead or device-related complications. A transiliac approach, in our opinion, is safe, effective, and could be the next step for CRT-D implantation when standard venous access approaches are unsuitable.

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Figure 1

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Figure 2

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Figure 3

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