Biventricular ICD Placement Percutaneously Via the Iliac Vein: Case Reports and a Review

Abstract

Cardiac resynchronization therapy (CRT) has been demonstrated to improve symptoms of heart failure. As a result, it has become the standard of care in selected patients, and is commonly completed with three leads placed via an upper-extremity vein. However, in rare situations, such as in the case of superior vena cava occlusion, venous access is not possible via the upper extremity. It is in such instances that alternative means must be sought. Here, two patients who received a CRT defibrillator via an iliac vein approach with a mid-abdominal generator are introduced, and a review of the techniques used is presented. Technical aspects to this approach are discussed, including iliac venous access, defibrillation electrode positioning, coronary sinus access, and lead tunneling to an abdominal generator for patient comfort. This approach should be considered when vascular access is compromised, at least until combined leadless CRT pacing and subcutaneous implantable cardioverter-defibrillator devices become available and feasible for use.

Keywords: Abdominal; biventricular implantable cardioverter-defibrillator; cardiac resynchronization therapy; femoral vein; iliac vein.

Figure 1:

Preoperative chest X-ray reveals only two transve-nous electrodes despite 40 years of pacing therapy. Also noteworthy for marked cardiomegaly and a horizontal substernal approach.

Figure 2:

Intraoperative venogram from a right subclavian sheath shows total occlusion of the SVC with retrograde flow via the azygous vein to the inferior vena cava.

Figure 3:

Postoperative computed tomography angiogram shows complete occlusion of the superior vena cava just above the right atrium (arrows).

Figure 4:

Postoperative posterioranterior chest radiograph showing two new transvenous leads inserted via the iliac vein. The CS lead is labeled, present in a basal posterolateral location. Note the insertion of the RV shocking lead in the mid-RV septum, chosen to separate the two defibrillation coils with RV myocardium between them (arrows).

Figure 5:

Intraoperative photograph, oriented with the patient’s head to the right. The leads were placed via iliac venous access and tunneled to a mid-abdominal wall subcutaneous pocket.

Figure 6:

Immediate postoperative view, with similar orientation, showing the two incisions required for venous access and the device pocket.

Figure 7:

A three-channel electrocardiogram showing a decrease in QRS duration with the resumption of biventricular pacing. Using 12-lead analysis, the QRS duration decreased from 165 to 135 ms with CRT pacing.

Figure 8:

Postoperative AP chest radiography for Case 2 showing three intracardiac leads. The right atrial lead is along the lateral mid-RA, the LV CS lead is a proximal middle cardiac vein (labeled), and the RV lead in the lower septum with separation between the defibrillation coils (black arrows).

Figure 9:

A right femoral venogram showing the external and internal iliac veins forming the common iliac vein near the pelvic crest. Inferiorly, the external iliac vein is called the common femoral vein. It is formed by the combination of the superficial femoral and the greater saphenous veins (not shown).