Transiliac ICD implantation: Defibrillation vector flexibility produces consistent success

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.

Keywords: Implantable cardioverter defibrillator, Transiliac approach, Defibrillation vector, Defibrillation testing, Complications, Leads