Received 10 January 2009; accepted 18 March 2009. published online 23 March 2009.
Background
The transiliac approach to implantable cardioverter-defibrillator (ICD) implantation is an alternative in patients for whom pectoral placements are contraindicated. The defibrillation vector is altered from the pectoral configuration because of pulse generator placement in one of the upper abdominal quadrants and separate single-coil, active-fixation defibrillation leads positioned in the high right atrium and right ventricular apex.
Objective
The feasibility, safety, and complications of this approach and the results of defibrillation testing (DFT) with this configuration are described.
Methods
Twenty-three patients (16 male and 7 female, mean age 65.7 ± 13.2 years) required transiliac approach to ICD placement. The leads were inserted through the iliac vein immediately superior to the inguinal ligament. When required, a subcutaneous coil was tunneled posterior to the left ventricle from the left axilla.
Results
The right iliac vein entry was used in 17 patients, with placement of the pulse generator in the left upper quadrant in 16 patients. Atrial and ventricular lead pacing and sensing function were acceptable. Initial defibrillation success with a safety margin of 10 J was achieved in 15 patients. With the placement of an additional subcutaneous coil in the remaining 8 patients, defibrillation success with a safety margin of 10 J was increased to 19 patients, whereas defibrillation success with a safety margin of 5 J was achieved in all patients, although 1 patient required repeat testing 24 hours after implantation. There were no acute complications. Late complications occurred in 3 patients, comprised of atrial lead malfunction, device infection, and right ventricular defibrillation lead fracture.
Conclusion
The iliac vein approach to ICD implantation is a safe and effective alternative technique. Flexibility in lead placement, defibrillation vectors, and careful DFT are required to produce a consistently effective system.
‡Department of Cardiology, University of Foggia, Foggia, Italy
Address reprint requests and correspondence: Dr. Bruce L. Wilkoff, Cleveland Clinic, 9500 Euclid Avenue J2-2, Cleveland, Ohio 44195
Bruce L. Wilkoff reports grant/research support from Guidant, Medtronic and St. Jude Medical. He is Consultant for Guidant, Medtronic, St. Jude Medical, Spectranetics and Cook Vascular. David O. Martin, speaker for St. Jude Medical, member advisory board for Medtronic, consultant for Boston Scientific. Oussama M. Wazni, speaker/consultant for Boston Scientific, Spectranetics, St Jude Medical. J. David Burkhardt, speaker for St Jude Medical, Biosense Webster and chief medical officer for Stereotaxis. Robert A. Schweikert, consultant for Biosense Webster, speaker for Medtronic, St Jude Medical, Boston Scientific, Biosense Webster and Reliant Pharmaceuticals, Walid I, Saliba, speaker for Biosense Webster, Medtronic, Boston Scientific and St Jude Medical. The other authors have no disclosures or conflict of interest.
ABSTRACT