Venous access for permanent pacing can be troublesome . Especially with anomalous subclavian , second implantation ,obese patients with upper limb DVT . Temporary pacing through femoral vein is a well known concept.
Here is a concept of implanting the PPM through femoral vein , in the upper thigh and the pacing lead all the way reaches the right ventricle .There were few issues which were thought to be critical .As patients ambulate there could be more generator motion than the sub pectoral location .(By the way , upper limb movement is equally common daily living is isn’t !)
Surprisingly excess motion is rarely an issue . Even dual chamber pacers were implanted through femoral approach.Implantation procedure are simpler than one would have thought and complications are less as well .Since most of the leads are now screwing type and actively fixed dis-lodgement is never an issue.
The femoral venous access can be considered in all in whom SVC approach is difficult or not possible . 85cm lead is ideal . It is routinely available.
Always consider trans-femoral approach whenever you encounter difficulty in subclavian . Falling back on epicardial approach in such cases should be avoided at all cost. After all , epicardial approach is a major procedure.
Unfortunately, very few centers practice transfemoral modality for PPM right now . Brazil has some experience I understand.Royal Brompton hospital ,London , Memorial heart institute ,Long beach , California have advocated this approach with good success.
We Indians , have a huge potential to propagate this useful concept.I wonder why Femoral – IVC approach could not be a first choice for permanent pace maker implantation especially in small children and adults ! The main issue is not technical , it is more of perceived fear and reluctance to change the tradition.