Femoral Implant of a Dual-Chamber Pacemaker: Another Alternative

The usual subpectoral implant sites for pacing leads may sometimes become unavailable because of venous obstruction or recent infection. We discuss a rarely used but valuable alternative for percutaneous implantation of a dual-chamber pacing system via the femoral vein.

Patient History

The patient is a 70-year-old male who resides in Florida. While visiting family in Pennsylvania on July 9, he collapsed. EMS was summoned and he was found to be in pulseless electrical activity. After successful resuscitation, the patient was transferred to a local hospital where he was treated with atropine and dobutamine. 

The patient has a history of atrial fibrillation, coronary artery disease (CAD), coronary artery artery bypass grafting (CABG), and mitral valve (MV) repair in 2001, as well as redo CABG and a MV replacement in the same year via sternotomy approach. In 2003, he had a thoracotomy and reseating of his mechanical valve. He received a BIOTRONIK pacemaker in 2009 with bipolar epicardial leads (MyoPore Sutureless Bipolar Epicardial Pacing Lead, Model 511212, Greatbatch Medical), and now presents with RV lead failure culminating in his arrest. 

LV epicardial lead testing demonstrated a markedly increased pacing threshold and presumed subsequent loss of capture leading to his cardiac event. The patient was known to have a totally occluded SVC without any possibility of transvenous lead placement via a standard superior approach.

Options

Given the occluded SVC, several treatment options existed, including replacement/implant of epicardial RA and RV leads (although the risk of this would be high given two prior sternotomies and a thoracotomy), or leadless pacemaker implantation. The cardiovascular surgeons determined that he was too high a risk for surgical intervention, and leadless pacemaker implant was ruled out due to the inability to provide A-V synchrony and questions about follow-up with his medical team at home. The treatment team ultimately decided to attempt implantation of transvenous femoral leads with an abdominal generator.

Venous Evaluation 

The patient had an extensive venous evaluation in the EP lab. Left and right venograms confirmed a totally occluded SVC and the lack of target veins that could be used to connect the SVC. The superior veins only provided small collaterals, and thus, did not represent a target that could be used to laser between the SVC and the veins above.

The right and left axillary veins were accessed using 18 gauge Cook Medical needles and short wires, and were exchanged for a 150 cm glide wire. A 5 French (Fr) hydrophilic vertebral catheter was then advanced over the Glide Wire (Terumo) and subsequently into a number of branches. A left subclavian venogram demonstrated total occlusion of the axillary veins (Figure 1). Subsequent selective venograms demonstrated multiple collaterals (Figure 2). 

A right axillary venogram was performed. This demonstrated a totally occluded axillary vein (Figure 3). A failed attempt was made to cross the total occlusion with a Terumo wire and a vertebral catheter.

Pacemaker Implant

The patient was brought to the EP lab for permanent pacemaker implantation. Access was obtained in the right femoral vein. This provided a target for access above the inguinal ligament. An 8 Fr Preface guiding sheath (Biosense Webster, Inc., a Johnson & Johnson company) was inserted and advanced to the right atrium over a glide wire. An Impulse 5 Fr catheter (Boston Scientific) was advanced into the RA and a power dye injector was then used to perform a right atriogram, which confirmed complete occlusion of the SVC at the RA-SVC junction (Figure 4). 

To implant the pacemaker, we accessed the right iliac vein twice, just above the inguinal crease. We advanced a Tendril STS pacing lead (2088TC/100, St. Jude Medical) through a 7 Fr Prelude SNAP^™ introducer (Merit Medical) into the right atrium and assessed fixation of the lead by the current injury recorded from the right atrial electrogram. After obtaining satisfactory sensing and pacing thresholds, the sheath was split and removed. 

A second Tendril STS pacing lead (2088TC/100, St. Jude Medical) was advanced to the right ventricle through a second 7 Fr Prelude SNAP^™ introducer (Merit Medical) and positioned in the right ventricular septum. After obtaining satisfactory sensing and pacing thresholds, the sheath was split and removed. Care was taken to provide enough slack of the leads to prevent dislodgement.  

A vertical incision was then made around the leads and dissected to the rectus abdominis muscle, and the leads were secured with the suture sleeves on each lead. A horizontal incision was made to the right of the umbilicus, and a pocket was fashioned with blunt dissection. Leads were then tunneled from the right lower quadrant (RLQ) incision to the pocket and attached to an Assurity dual-chamber pacemaker (PM2240, St. Jude Medical). The generator was placed inside a Medtronic TYRX absorbable antibacterial envelope and secured in the pocket; the wound was then closed. 

Follow-up pacemaker testing showed excellent pacing and sensing parameters with an atrial threshold of 0.75 V at 0.5 ms, ventricular threshold of 0.5 V at 0.5 ms, and P and R waves of 2.2 mV and 6.9 mV, respectively. Atrial impedance was 610 ohms and RV impedance was 590 ohms. Interrogation also revealed 98% atrial pacing and 1% ventricular pacing.

Discussion

This case provided an interesting challenge due to the fact that no endocardial leads were available to be lased or otherwise changed out, and the patient was no longer a candidate for epicardial leads. He also needed dual-chamber pacing. 

The femoral vein approach for permanent pacemaker implantation has been reported on since the early 1980s.¹ One might expect an increased incidence of lead fracture with the femoral approach given the “U-turn” from the venous entry site to the generator pocket, but the literature does not support this. The groin is probably a much less mobile region than the subpectoral area, especially in elderly patients, and does not have the equivalent for the clavicle to inflict crush injuries.

Another concern with the femoral approach is lead dislodgement, especially for the atrial lead. Gravity may play an important role in this, as the whole length of the lead is suspended from its anchor point in the myocardium, in contrast to leads inserted from the pectoral area. Two authors reported approximately 20% atrial lead dislodgement-,^2,3 although initial implant technique seems to have played a major role in these statistics. 

Recent implanters using the femoral approach and newer generation fixation leads have had notable success, with no complications or lead dislodgement.^4,5

In conclusion, the femoral approach provides a good alternative when the standard pectoral implant route is unavailable. The morbidity is low and the technique is relatively easy when compared with other alternative implant techniques.

The patient was discharged from the hospital following a pacemaker parameter test, which demonstrated normal sensing and pacing parameters. He has since returned to his home in Florida. 

Disclosures: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Worley reports personal fees from Pressure Products, Merit Medical, St. Jude Medical, Medtronic, Bristol-Myers Squibb, and Pfizer. 

References

1. Ellestad MH, Caso R, Greenberg PS. Permanent pacemaker implantation using the femoral vein: a preliminary report. Pacing Clin Electrophysiol. 1980;3(4):418-423.
2. Ellestad MH, French J. Iliac vein approach to permanent pacemaker implantation. Pacing Clin Electrophysiol. 1989;12(7 Pt 1):1030-1033. 
3. Mathur G, Stables RH, Heaven D, Ingram A, Sutton R. Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach. Europace. 2001;3(1):56-59.
4. Xiong W, Tobler HG, Paydak H. Permanent transfemoral pacemaker: an exceptional approach. Journal of Innovations in Cardiac Rhythm Management. March 2011.
5. Bracke FA, Ozdemir I, van Gelder B. The femoral route revisited: an alternative for pectoral pacing lead implantation. Neth Heart J. 2010;18(1):42-44.