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CARDIOVASCULAR ANESTHESIA

Safe and Efficient Emergency Transvenous Ventricular Pacing via the Right Supraclavicular Route

Klaus Laczika, MD^*, Florian Thalhammer, MD^*, Gottfried Locker, MD^*, Robert Apsner, MD, Heidrun Losert, MD^*, Julia Kofler, MD^*, Werner Rabitsch, MD^*, Peter Mares, MD, Michael Frass, MD^*, Gere Sunder-Plassmann, MD, and Manfred Muhm, MD^*,,

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

	Abstract

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Infraclavicular and internal jugular central venous access are techniques commonly used for temporary transvenous pacing. However, the procedure still has a considerable complication rate, with a high risk/benefit ratio because of insertion difficulties and pacemaker malfunction. To enlarge the spectrum of alternative access sites, we prospectively evaluated the right supraclavicular route to the subclavian/innominate vein for emergency ventricular pacing with a transvenous flow-directed pacemaker as a bedside procedure. For 19 mo, 17 consecutive patients with symptomatic bradycardia, cardiac arrest, or torsade de pointes requiring immediate bedside transvenous pacing were enrolled in the study. The success rate, insertional complications, pacemaker performance, and patients’ outcomes were recorded. Supraclavicular venipuncture was successful in all patients, in 16 of 17 at the first attempt. Adequate ventricular pacing was achieved within 1 to 5 min (median, 2 min) after venipuncture and within 10 s to 4 min (median, 30 s) after lead insertion (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.

	Introduction

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Rapid establishment of cardiac pacing is a life-saving intervention in a variety of critical clinical situations. Aside from the option of noninvasive transcutaneous pacing (1), the transvenous ventricular pacemaker (PM) is the most common way of temporary pacing because it is effective, comfortable, and stable if correctly positioned (2). However, rapid central venous insertion of a standard transvenous PM electrode usually requires expert skill, in particular because the procedure is hazardous under emergency conditions.

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.

	Methods

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Between December 1997 and June 1999, 17 hemodynamically compromised patients (8 female, 9 male; median age, 68 yr; range 48–85 yr) with symptomatic bradycardia (n = 11), cardiac arrest (n = 4), or torsade de pointes (n = 2) at the medical intensive care unit of the Department of Internal Medicine I, Vienna University Hospital were enrolled in the study after approval by the institutional human investigation committee. Patients’ characteristics, underlying diseases and indications for pacing are given in Table 1.

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.

View larger version (58K): [in this window] [in a new window]   Figure 1. Anatomical sketch of surface landmarks for supraclavicular cannulation. 1 = clavicle, 2 = clavicular head of the sternocleidomastoid muscle, 3 = right innominate vein, 4 = superior caval vein.

	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).

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).

	Discussion

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Temporary transvenous cardiac pacing is integral to the management of a variety of life-threatening situations. Technical progress, such as the replacement of stiff-woven Dacron catheters by balloon-tipped PM leads (22), has facilitated PM implantation, shortened insertion time and lowered the frequency of serious ventricular arrhythmias during insertion (22). However, the procedure still has a considerable complication rate resulting in a high risk/benefit ratio (3,12–15) because of puncture-related adverse effects and the operating physicians’ experience in an emergency setting.

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.

1. Surface landmarks are easy to define (17,20,21), and supraclavicular venipuncture yields high success rates even if performed by relatively inexperienced physicians and/or during CPR (24). This position produces minimal physical encroachment on other staff members performing concomitant CPR and, thus, results in low interference. Our results of six patients paced sufficiently during CPR reflects this advantage. It is therefore suggested that supraclavicular pacing could be used with comparable beneficial results also in the emergency setting outside of the hospital.

2. The correct insertion position provides a considerable distance from the pleural dome, thus limiting the risk of lung injury (17,20,25,26). This has been shown in larger series on the supraclavicular access (20,21,23–26) and is confirmed by the absence of pneumothorax in our patients, who were mechanically ventilated in 9 of 17 cases. Other serious complications, such as severe bleeding caused by arterial puncture, are uncommon with the supraclavicular approach (20,21,25,26).

3. Stenosis and/or old thrombotic occlusions of the subclavian or jugular veins caused by previous central venous cannulations are a frequent finding in chronically ill patients. They can negatively influence success rates of venipuncture and PM insertion, whereas the innominate vein remains mostly patent.

4. Transvenous PM malfunction is often caused by malposition or secondary dislodgement. The proper anatomically coaxial course between the vessel and the PM minimizes the incidence of malposition. This is of special importance, as balloon-tipped PM leads require an adequate blood flow to be manipulated into a suitable position (3) and can become unstable as a result of their flexibility. The straight path from the supraclavicular puncture site to the right ventricle might be an essential contribution to the achievement of sufficient lead performance even at low-flow states or during CPR. Dislodgement of a primary well positioned PM as a common cause of malfunction is often attributed to movements of the neck and the arms but was not observed in our series. However, our series is too small for drawing any definite conclusion about this. It might be hypothesized that, with use of the supraclavicular route, any traction on the catheter is minimized, thus reducing the incidence of secondary PM dislocation. Immobilization of limbs may therefore not be necessary (18). Analogous to our large series with supraclavicular-placed Hickman catheters, secondary migration was observed only in 1.2% of the patients (21).

5. If the subsequent implantation of a permanent PM is warranted, the infraclavicular route has not be violated.

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.

	Acknowledgments

 
This paper is dedicated to Manfred Muhm for kissing awake the sleeping beauty of supraclavicular central venous access.

	References

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