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,
Departments of
*Internal Medicine I, Division of Intensive Care,
Internal Medicine III, Division of Nephrology and Dialysis, and
Cardiothoracic/Vascular Anesthesia & Intensive Care, Vienna University Hospital, Vienna, Austria
Address correspondence reprint requests to Dr. Klaus Laczika, Department of Internal Medicine I, Intensive Care Unit, Vienna University Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria. Address e-mail to Klaus.Laczika{at}akh-wien.ac.at
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Abstract |
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30 s in 15 of 17 patients). The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA). No procedure-related complications were recorded. Throughout the pacing period of 1538 h (median: 62 h, range, 1–280 h) two reversible malfunctions caused by inadvertent lead dislodgement after 122 and 171 h were recorded; in one patient the pacemaker had to be removed because of local infection after 14 days of pacing. We conclude that the right supraclavicular route is an easy, safe, and effective first approach for transvenous ventricular pacing and might provide a useful alternative to traditional puncture sites, even in a preclinical setting. Implications: Temporary transvenous cardiac pacing can yield high complication rates especially under emergency conditions. We investigated emergency pacing via the right supraclavicular access in 17 consecutive hemodynamically compromised patients and found good safety, efficacy, and a low complication rate.
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Introduction |
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The proper choice of the insertion site is essential for success. Historically, most authors have recommended either the infraclavicular cannulation of the subclavian vein or the right internal jugular venous approach (2–7) for transvenous ventricular PM implantation. In emergency situations, the infraclavicular cannulation is limited by a high rate of complications (e.g., pneumothorax), and frequently results in catheter malposition, especially if performed from the right side (8–11). The internal jugular approach can be impeded by hypovolemia or simultaneous cardiopulmonary resuscitation (CPR). Alternatives other than PM insertion via the brachial or femoral vein are time consuming and associated with complications in as many as one half of procedures (3,12–16). The incidence of malfunction varies between 12% and 43% (3,12,13). These sites are therefore not suitable for an emergency setting.
As early as 1965, Yoffa (17) described supraclavicular subclavian venipuncture and catheterization for insertion of infusion catheters. However, the supraclavicular approach has never gained broad acceptance, although Yoffa (17) emphasized 1) a low complication rate, 2) the advantage of a definitive skin landmark (the "sternoclavicular angle"), 3) the short distance between the skin and the vein, and 4) that in contrast to the infraclavicular approach, only fascial tissue is pierced. For temporary transvenous pacing, the supraclavicular route has been reported only in small cohorts and was only used with additional technical expenditure, such as fluoroscopic guidance (18) or with a J-tipped introducer sheath (19).
Our previous favorable experience with the supraclavicular approach to the subclavian/innominate vein for dialysis catheters (20) and Hickman catheters (21) has shown overall success rates of nearly 100% and of 90% on the first attempt in association with a 1% incidence of misdirections. Thus, we hypothesized that the supraclavicular central venous access can be used for emergency transvenous pacing without any additional time consuming aids. To overcome the shortcomings of the "traditional" infraclavicular or internal jugular approaches and to enlarge the spectrum of suitable alternative access sites, we prospectively investigated right-sided supraclavicular venipuncture for surface-electrocardiogram guided emergency pacing as a bedside procedure.
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Methods |
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In conscious patients, local anesthesia was performed by injecting 2–5 mL of 2% lidocaine. The needle was then introduced into the sternoclavicular angle (Fig. 1) and advanced under aspiration caudally at an angle of 30°–40° to the sagittal plane and of 10°–15° anterior to the coronal plane. Vessel puncture was verified by aspiration of venous blood and a guidewire was introduced. After a 0.2-cm incision at the puncture site was made, the dilator was inserted to dilate the access to the vein and was then replaced by the percutaneous hemostatic introducer sheath (6F; Arrow International, Reading, PA). The flow-directed, balloon-tipped PM leads (Baxter Edwards Swan Ganz Bipolar Pacing Catheter, 5F; Baxter Healthcare Corporation, Irvine, CA) were connected to the pulse generator (Medtronic Model 5330, Medtronic Inc., Minneapolis, MN). The generator rate was set at pacing status at a high current level (stimulus amplitude 5 mA) with a pacing rate 20 bpm above the patient’s ventricular rate (or at a fixed mode at a minimum of 70 bpm in case of cardiac arrest), and the PM was then introduced into the vein. Surface electrocardiogram was used to monitor cardiac rhythm and to detect capture. After satisfactory lead performance and hemodynamic stabilization of the patient, a safety margin of twice the minimal threshold value was set. If the patients were conscious, they were asked to cough while the PM was maintained at the stimulation threshold. The lead was felt to be in a stable position if the PM remained functioning. Postprocedural chest radiography was performed to establish correct lead position and to exclude complications. If sterility was violated during insertion because of the highly emergent situation, antibiotic prophylaxis with penicillin G and flucloxacillin was initiated.
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Results |
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Success Rate
The results are summarized in Table 2. Sufficient pacing was established in all 17 patients (100%). Successful supraclavicular venipuncture at an average depth of approximately 2 to 4 cm from the skin was achieved in 16 of 17 patients on the first attempt, in 1 patient (Patient 2) at a second attempt. In one patient (Patient 2) the first attempt resulted in diaphragmatic pacing as a result of PM misdirection into the inferior vena cava. Adequate lead performance was achieved at a second attempt of PM positioning. In another patient receiving CPR (Patient 12), rhythmical involuntary movements of the right upper extremity secondary to electrical stimulation of the brachial plexus revealed misdirected PM position in the right cephalic vein, which was attributed to a kinked introducer sheath. A second right-sided supraclavicular PM was inserted immediately and resulted in acceptable pacing. Overall, pacing was initiated successfully within 1 to 5 min (median, 2 min) of venipuncture and within 10 s to 4 min (median, 30 s) of lead insertion. In 15 of 17 patients, acceptable lead performance was achieved within 30 s. The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA).
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Complications and PM Function
No serious complications occurred despite the presence of several factors that might have increased the risk of the procedure: simultaneous CPR (n = 6), significant bleeding diathesis caused by warfarin or heparin therapy or thrombolysis (n = 10), and mechanical ventilation using positive end-expiratory pressure (n = 9).
No complications related to central venous cannulation such as arterial puncture, pneumothorax, hemothorax, air embolism, or brachial plexus injury were recorded.
Ventricular premature beats were stimulated in 2 of 17 patients (Patients 2 and 15) as was a nonsustained ventricular tachycardia in one patient (Patient 16). No damage to the tricuspid value or cardiac perforation were recorded in clinical and echocardiographic follow-up.
Two patients (Patients 7 and 12) experienced PM lead dislodgement-induced during transfer to another bed after 171 h of pacing (Patient 7) and by self-manipulation by a patient after 122 h (Patient 17), both leads could easily be repositioned at first attempt at bedside without fluoroscopy. In none of the other patients was lead performance violated, not even in the four patients with adult respiratory distress syndrome undergoing kinetic therapy with repeated daily changes from the supine to prone positions. Regular retesting of pacing thresholds did not reveal clinically significant changes.
Follow-up
The duration of pacing and the indications for removal of PM are listed in Table 2. The 17 patients were paced over a total period of 1538 h (median, 62 h; range, 1–280 h).
Throughout the entire observation, no instances of migration, perforation, or tamponade were recorded. In one patient (Patient 12), in whom implantation of a permanent PM had to be postponed because of preexisting sepsis, a local infection at the PM entry site was noted on Day 14. The temporary PM was then replaced to a left infraclavicular insertion site.
Outcome
Temporary PM leads with well preserved function were electively removed after restoration of cardiac rhythm in 7 of 17 patients or were replaced by a permanent PM in 5 of 17 patients. Four of the 17 patients died as a result of their underlying disease, despite adequate PM performance. Only one PM (in Patient 12) had to be exchanged because of a local infection at the entry site. Seven of 17 patients could be discharged from hospital with the remaining 10 of 17 intensive care unit patients (including all six patients paced sufficiently during CPR) not surviving the hospital stay (Table 2).
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Discussion |
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The proper central venous access site is controversial. Essentials of an applicable central venous access for temporary transvenous pacing are 1) a high success rate, 2) a low incidence of complications, and 3) avoidance of PM lead misdirections, as any malposition impairs satisfactory pacing. A minimum of technical expenditure and time required for insertion is desirable.
An analysis of our series confirms that the supraclavicular approach is an acceptable alternative to commonly used infraclavicular and internal jugular puncture, even for rapid transvenous pacing as a bedside procedure. Comparable to our previous experience with supraclavicular access for large-bore catheters (20,21), we successfully located the vein on the first attempt in 94.1% (overall success rate 100%). Furthermore, once venous access has been gained, the anatomically proper coaxial course between the vessel and the PM sheath minimizes the incidence of misdirection and enables rapid PM advancement. This resulted in adequate ventricular pacing within less than 30 seconds after insertion in nearly all patients. In none of the patients, was fluoroscopic guidance required, and the complication rate was low. In a recent review, Murphy (16) reported an incidence of unsuccessful pacing attempts as high as 16.6% via the infraclavicular route and 8.3% via the right internal jugular vein. Our results compare favorably with these findings and suggest that the greatest advantage of supraclavicular access is over the infraclavicular route.
In fact, in most critical clinical situations, infraclavicular access to the subclavian vein is preferred to the jugular vein because of its high patency rate, even in hypovolemic shock. However, besides other insertion complications from the infraclavicular approach, the narrow gap between the first rib and the clavicle can cause kinking of the guidewire and compression of the introducer sheath. This results in difficulties in feeding the catheter in up to 25% of patients (23) or even in sheath introducer damage (23). In contrast, the use of the supraclavicular technique avoids the narrow gap and kinking of the introducer sheath, because the puncture channel and the innominate vein are located approximately in the same coronal plane behind the clavicle (21). Indeed, once the guidewire was in place, the feeding of the sheath and the PM was possible in all our supraclavicular punctures. Misplacement into adjacent vessels in up to 6% of infraclavicular cannulations (8–11), related to the sharp angle between the right subclavian vein and the innominate vein, has not been observed in our supraclavicular series. The straight path of the PM into the right ventricle facilitates proper positioning without fluoroscopic guidance.
A variety of arguments support use of the right supraclavicular approach for ventricular pacing in emergency situations.
The supraclavicular approach has been touted in the past without being widely accepted, and physicians have viewed this method with hesitance. Regarding safety and efficacy, our results confirm recent studies that indicate that the "forgotten landmark" (27) is at least as safe and efficient as traditional alternatives. Temporary cardiac pacing is a necessary skill for the management of life-threatening arrhythmias (11), and it is suggested that even inexperienced operators might find the supraclavicular approach to be a useful alternative to other routes of access to the central venous circulation.
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Acknowledgments |
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References |
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This article has been cited by other articles:
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  R. L. Bush, P. H. Lin, C. C. Bianco, J. E. Hurt, T. I. Lawhorn, and A. B. Lumsden Reevaluation of Temporary Transvenous Cardiac Pacemaker Usage During Carotid Angioplasty and Stenting: A Safe and Valuable Adjunct Vascular and Endovascular Surgery, May 1, 2004; 38(3): 229 - 235. [Abstract] [PDF]
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 Supraclavicular Route for Emergency Transvenous Pacing Journal Watch Emergency Medicine, July 5, 2000; 2000(705): 6 - 6. [Full Text]
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