Dr.S.Venkatesan MD

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.

Final message

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.

Reference

The  article  by Ellsted  http://onlinelibrary.wiley.com