An Unorthodox Solution for Occluded Superior Vena Cava and Failed Epicardial Pacing

Introduction: Complete heart block requiring permanent pacemaker implantation is typically managed via upper limb veins. However, in rare cases where the superior vena cava (SVC) is completely occluded, alternative approaches must be considered. This case study explores an unconventional yet effective solution for such a scenario. Visit https://www.cardiologymedjournal.org/jccm for more groundbreaking research in this field.

Background

Permanent pacemaker implantation via conventional routes is not always possible. SVC occlusion, occurring in 1%–6% of cases, poses a significant challenge. While epicardial pacing is an option, it carries risks such as increased battery drain and lead failure.

Case Summary

A 49-year-old patient with a history of complete heart block and an occluded SVC required an alternative approach after his epicardial lead failed prematurely. Given the resource constraints and failed lead extraction attempts, the team opted for a transiliac endocardial pacemaker implantationa rarely utilized yet effective method.

Alternative Access and Surgical Approach

• Procedure: Pacemaker implantation via the right external iliac vein (EIV) under local anesthesia.
• Technique:
  • Guidewire placement in the right common iliac vein.
  • Fluoroscopy-guided puncture of the right EIV.
  • Lead fixation in the right ventricle with an alpha loop to prevent dislodgement.
  • Subcutaneous lead tunneling to a lumbar pacemaker pocket.
• Outcome:
  • Successful implantation with satisfactory pacing parameters.
  • No post-operative complications.
  • The patient remained asymptomatic at a six-month follow-up.

Integration of External Medical Sources

The American College of Cardiology (ACC) emphasizes the importance of alternative pacemaker implantation strategies in patients with venous occlusions, highlighting transiliac and leadless pacemakers as viable solutions.

Further Reading and Resources

• Read the full study at: https://doi.org/10.29328/journal.jccm.1001079
• Explore more related cases at https://www.cardiologymedjournal.org/jccm

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