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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 158-160

Transhepatic venous approach to permanent pacemaker implantation in a patient with no conventional access site

1 Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
2 Department of Radiology, Dr. C. M. Poojari Nursing Home, Mumbai, Maharashtra, India

Date of Submission30-Jun-2020
Date of Decision04-Jul-2020
Date of Acceptance04-Jul-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Dr. Nitesh Karnire
L-5/39, Vrindavan Colony, Tilak Nagar, Chembur, Mumbai, Maharashtra.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.mgmj_52_20

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Permanent pacemakers are generally done through subclavian venous access. We present a case of transhepatic venous approach to a permanent pacemaker in a patient who had bilateral obstructed subclavian vein and superior vena cava (SVC) secondary to previous permanent pacemaker infection.

Keywords: Pacemaker infection, permanent cardiac pacemaker, transhepatic venous access

How to cite this article:
Karnire N, Dash PK, Pujary NC. Transhepatic venous approach to permanent pacemaker implantation in a patient with no conventional access site. MGM J Med Sci 2020;7:158-60

How to cite this URL:
Karnire N, Dash PK, Pujary NC. Transhepatic venous approach to permanent pacemaker implantation in a patient with no conventional access site. MGM J Med Sci [serial online] 2020 [cited 2022 Oct 1];7:158-60. Available from: http://www.mgmjms.com/text.asp?2020/7/3/158/292378

  Background Top

The left subclavian vein is the most preferred venous access for placing the right ventricle (RV) lead, but in patients with limited access alternative approaches include the right subclavian vein and iliac veins. In this case report, we describe an adult patient within whom both the subclavian veins were occluded. The femoral venous access could not be taken due to nonavailability of 69cm RV lead. Leadless pacemaker was an option, but due to financial constrains could not be done in this patient. The hepatic vein was the only available access to implant a single-lead permanent pacemaker.

A 62-year-old male patient had his Dual-Chamber, Rate-Modulated (DDDR) permanent Pacemaker completed in 2005. Pulse generator was replaced in March 2014 due to End of Life (EOL). The patient presented with deltopectoral pocket infection in May 2014. The pacemaker’s pulse generator was later explanted in May 2014. Pacemaker leads could not be explanted. Epicardial lead and left side permanent pacemaker were implanted on May 14.

Patient presented with Pulse Generator infection on January 1, 2016 and explanted on January 5, 2016.

Ventricular demand rate responsive (VVIR mode) implanted on the right side in January 9, 2016. The patient again presented with a pacemaker pocket infection in September 2018. Blood culture and swabs from pacemaker pocket grew Staphylococcus aureus.

Venogram was done to see venous access after multiple infections [Video 1].

  1. Venograms showed an occluded left subclavian vein.

  2. Left-arm veins drain into the superior vena cava (SVC) via collateral.

  3. The right subclavian was obstructed. SVC was obstructed just above right atrium (RA).

  4. Multiple collaterals were present which bypassed the obstruction in SVC.

  Procedure Top

Localization of hepatic vein for access: Judkin’s right (JR) catheter placed in the inferior vena cava (IVC) through femoral vein access. Venogam taken to localize the hepatic vein through injection in the IVC. Doppler ultrasound can also be used to localize the hepatic vein.

After localization of hepatic vein, access taken in the hepatic vein via seldinger technique. RV Lead placed in the RV septum through hepatic vein. RV leads attached to the pulse generator and a surgical pocket was created in the subrectus sheath and the pacing lead was connected to the generator [Video 2]A–C and [Video 3], and [Figure 1].
Video 2: (A) Localizing the hepatic vein with JR catheter in hepatic vein through femoral vein. (B) Needle insertion in hepatic vein. (C) Hepatic vein entered via Seldinger technique

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Video 3: Permanent pacemaker through transhepatic route with pacemaker battery in the rectus sheath

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Figure 1: X-ray chest and upper abdomen: pacemaker leads from previous pacemaker seen. Epicardial leads also can be seen. New pacemaker with pacemaker battery in rectus sheath with the RV leads introduced into the RV through transhepatic route

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  Discussion Top

The main challenge in this case was to implant a pacing lead in the RV septum with no central venous access in the right and left upper extremities. The femoral venous access could not be taken due to nonavailability of 69cm RV lead. Leadless pacemaker can be used in such condition, but due to cost factor patient could not afford it. If no direct access via the SVC is possible, RV pacing lead placement can be performed epicardially; however, this approach requires an invasive thoracotomy and shows a high threshold and amplitude. Patient had already undergone epicardial lead placement which was once infected. Transhepatic access for RV lead implantation can be a useful alternative route to obtain access to the heart and vascular structures in patients with limited central venous access. Various authors have utilized transhepatic venous access for lead placement and for ablation procedure when traditional venous access was not available.[1],[2],[3] Permanent pacemaker lead implantation via azygous vein was implanted in a patient with silent SVC syndrome.[4]

Current literature states complication rates are <5% and include line sepsis, catheter migration, thrombosis, and bleeding.[5] Other complications that might occur in transhepatic approach include hepatic bleed into the peritoneum or in the subcutaneous plane. This generally occurs during procedure.[6]

  Conclusion Top

  1. Compared to the femoral vein access, in the hepatic vein access the pocket can be made in the abdomen, the pacemaker is more stabilized in abdomen compared to the groin.

  2. Pacing lead traverses the substance of the liver, and therefore is subject to respirophasic diaphragmatic excursions potentially leading dislodgement. Provide more than the usual redundancy in the RA to minimize dislodgement of the lead.[7]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Fishberger SB, Camunas J, Rodriguez-Fernandez H, Sommer RJ Permanent pacemaker lead implantation via the transhepatic route. Pacing Clin Electrophysiol 1996;19:1124-5.  Back to cited text no. 1
Cha MJ Two cases of transhepatic implantation of cardiac implantable electronic device: All roads lead to Rome. Int J Arrhythm 2017;18: 209-14.  Back to cited text no. 2
Singh SM, Neuzil P, Skoka J, Kriz R, Popelova J, Love BA, et al. Percutaneous transhepatic venous access for catheter ablation procedures in patients with interruption of the inferior vena cava. Circ Arrhythm Electrophysiol 2011;4:235-41.  Back to cited text no. 3
Goktekin O, Besoglu Y, Dogan SM, Birdane A, Unalir A, Gorenek B, et al. Permanent pacemaker lead implantation via azygous vein in a patient with silent superior vena cava syndrome. Int J Cardiol 2007;117:e4-6.  Back to cited text no. 4
Stavropoulos SW, Pan JJ, Clark TW, Soulen MC, Shlansky-Goldberg RD, Itkin M, et al. Percutaneous transhepatic venous access for hemodialysis. J Vasc Interv Radiol 2003;14:1187-90.  Back to cited text no. 5
Erenberg FG, Shim D, Beekman RH Intraperitoneal hemorrhage associated with transhepatic cardiac catheterization: A report of 2 cases. Cathet Cardiovasc Diagn 1998;43:177-8.  Back to cited text no. 6
Siddiqui AM, Harris GS, Movahed A, Chiang KS, Chelu MG, Nekkanti R Transhepatic venous approach to permanent pacemaker placement in a patient with limited central venous access. World J Clin Cases 2015;3:835-7.  Back to cited text no. 7


  [Figure 1], [Video 1], [Video 2], [Video 3]


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