Left Cephalic Vein Research Articles

Pneumopericardium and Pneumothorax After Permanent Pacemaker Implantation

We present a patient with chronic obstructive pulmonary disease who developed discomfort 2 days after dual-chamber pacemaker implantation via the left cephalic vein approach. The pacer was placed with active-fixation leads without obvious complications. A computed tomography (CT) scan taken in the emergency room showed right pneumothorax and associated pneumopericardium without pneumomediastinum. A three-dimensional reconstruction of CT images confirmed the atrial lead protruding into the pleural space. This lead likely ruptured a bulla causing a pneumothorax followed by pneumopericardium through a pleuro-pericardial communication. Chest tube placement relieved both pneumothorax and pneumopericardium without the need for atrial lead extraction.

Preserving the left arm vein in cases of hemodialysis access generating left internal mammary artery steal syndrome

In patients undergoing chronic hemodialysis (HD) through an arm arteriovenous fistula (AVF), coronary insufficiency can occur if the patient undergoes a coronary artery bypass graft (CABG) using the ipsilateral internal mammary artery (1-4). Therefore, the creation of a new AVF after CABG should avoid using the arm ipsilateral to the side where the internal thoracic artery was used. In cases where coronary syndrome appears when this advice is not followed, treatment should be offered aimed at overcoming the hemodynamic interference between the diminished coronary supply through the left or right internal mammary artery by closure of the existing fistula, with or without temporary central venous line insertion until the maturation of a new fistula. We suggest a different approach by moving only the arterial inflow site of the AVF to the controlateral subclavian artery, but in addition, leaving the well functioning venous outflow tract intact. In cases of left internal mammary steal it is achieved by creating a conduit running from the right subclavian artery to the left cephalic vein; therefore, creating a new arterial inflow source, connected to the existing functioning old venous outflow tract to maintain an immediately functioning new fistula without a coronary steal.

Desaparición del generador de marcapasos

Rev Esp Cardiol 2003;56(4):407 407 An 83-year-old woman with a history of VVI pacemaker implantation 10 years earlier due to complete atrioventricular block. Four months previously at another hospital she had undergone elective replacement of the generator as it was worn out, and she was admitted at the present time for syncope. She lived alone and presented with senile dementia and blindness due to glaucoma in the right eye. On ECG complete atrioventricular block was seen with a ventricular escape rhythm of 35 beats/minute and morphology of an advanced block of the right branch of the bundle of His. Stimulation flutter was not seen. On physical examination, the generator pocket appeared edematous and swollen, with continuity solution on the skin, but the generator was not located on palpation. Chest radiography showed the absence of the pacemaker generator and interruption of the electrode. In addition, continuity fluid was seen on the electrode (Figure 1, arrow). On questioning the patient again, she remembered that she had cut the pacemaker cable and given the generator to the attending cardiologist. Figure 2 shows the pacemaker generator with intentional cutting of the cable, the partially closed exterior wound (arrow), and the surgical wound, with staples, used for the revision and electrical isolation of the remaining electrode. Staphylococcus aureus was isolated in a wound culture, and treatment was begun with intravenous vancomycin. We decided to proceed to the isolation of the pacemaker electrode and the implantation of a new stimulation system via dissection of the left cephalic vein.

Subcutaneous Single-Incision Implantation of Cardioverter-Defibrillators Under Local Anesthesia by Electrophysiologists in the Electrophysiology Laboratory

Implantable cardioverter-defibrillators (ICDs) have traditionally been implanted at the operating room under general anesthesia. Endocardial lead systems and downsized devices allowed implantation by electrophysiologists in the pectoral region. The present study evaluates the safety and efficacy of subcutaneous ICD implantation performed entirely by electrophysiologists using a single-incision approach for lead insertion and device placement under local anesthesia. Between June 1996 and May 1997, 51 of 52 consecutive patients (41 men and 10 women, mean age 58 ± 9 years) underwent ICD implantation at the electrophysiology laboratory. Local anesthesia and intravenous sedation were administered to all patients. After transvenous lead positioning by either venotomy of the left cephalic vein (n = 16) or puncture of the left subclavian vein (n = 35), all ICDs were implanted subcutaneously at the left subclavicular region. Fifty procedures (98%) were successful at first attempt. The mean implantation time was 76 ± 22 minutes and the mean fluoroscopy time was 7.5 ± 5.2 minutes. Patients received ICD devices generating biphasic waveforms. The mean defibrillation threshold was 11 ± 3 J. Procedure-related complications occurred in 5 patients (10%): 1 lead dislocation, 2 pocket hematomas, and 2 pneumothorax requiring drainage. Mean time from implantation to hospital discharge was 1.8 ± 1.2 days. During follow-up (38 ± 14 weeks), all devices were operating appropriately and no major complications occurred. In conclusion, this report demonstrates that a single-incision subcutaneous technique for ICD implantation can be safely and successfully performed by electrophysiologists using local anesthesia and intravenous sedation. The high success rate, low complication occurrence, and short implantation and fluoroscopy times make this cost-effective technique in the electrophysiology laboratory the method of choice.

Cerebrovascular effects of the bradykinin analog RMP-7 in normal and irradiated dog brain.

The effects of an intravenous (i.v.) injection of the bradykinin analog RMP-7 (100 ng/kg) were assessed in normal dogs and dogs with focal, radiation-induced brain lesions. A dose of 20 Gy was delivered to a point 0.75 cm from a removable interstitial 125I source; parameters relating to blood flow and permeability were quantified using computed tomography 2-8 weeks after irradiation. Blood flow-related endpoints included regional cerebral blood flow (rCBF), mean transit time of blood and vascular volume, while endpoints related to permeability included blood-to-brain transfer constant (Ki), brain-to-blood transfer constant and plasma volume. In unirradiated brain, an i.v. bolus of RMP-7 administered through the left cephalic vein induced a rapid and transient hypotension and a statistically significant increase in vascular volume; no alterations in any parameter related to permeability were observed. After irradiation, changes in rCBF after RMP-7 depended upon time after exposure, effects presumably due to changing morphology in the irradiated tissues. In the radiation lesions, significant increases in Ki were observed 5 minutes after injection of RMP-7, but those increases were not related to time after irradiation or alteration in blood flow-related parameters. Our results showed that RMP-7 selectively increased permeability in already damaged vasculature without affecting the extent or volume of radiation-induced vasogenic edema. These data suggest that RMP-7 may provide an effective means to enhance the delivery of compounds to an already compromised brain while not exacerbating the potential adverse effects of pre-existing vasogenic edema.

Fully transvenous cardioverter defibrillators: Rare need for subcutaneous patch with two newer-generation systems

In published series of nonthoracotomy ICDs, there has invariably been a need for combining transvenous lead(s) with a subcutaneous patch to obtain adequate DFTs. Since the newer generation transvenous lead ICD systems became available for clinical investigation, we have tested and implanted 38 such systems in patients with drug-refractory malignant ventricular arrhythmias who were first seen with aborted sudden death ( n = 10), syncope ( n = 3), or sustained ventricular tachycardia ( n = 25). These patients (mean age 60 ± 15 years) had coronary artery disease ( n = 25), congenital heart disease ( n = 1), or cardiomyopathy ( n = 12) as the underlying heart disease and a mean left ventricular ejection fraction of 34% ± 16%. Seventeen (45%) patients had previous cardiac surgery (coronary bypass and/or valve replacement). The transvenous lead system included the Endotak C (single) lead of CPI ( n = 27) or the EnGuard double-lead system of Telectronics ( n = 11). The integrated pace/sense/defibrillation lead(s) were usually introduced via the left cephalic vein; after endocardiac positioning and testing, the leads were tunneled to the abdominal pocket in which the ICD device was implanted. DFTs were adequate for all patients (100%) and averaged 13.5 ± 5.4 J (range 2.4 to 25 J). A subcutaneous patch or array was needed in only three patients. Because of protocol requirements, a subcutaneous patch or electrode array was intraoperatively tested in another three patients but was finally not implanted because better DFTs were achieved with the transvenous lead-alone configuration. The leads were combined with second-generation devices in 12 patients and third-generation ICDs in 26 (68%) patients. Lead dislodgement required revision in 2 patients; 1 patient had ipsilateral venous thrombosis successfully treated with anticoagulation. At predischarge testing, all devices functioned well. We conclude that with the newer generation transvenous lead ICD systems there is rarely need for a subcutaneous patch, making possible pure transvenous ICD implants in the majority (92%) of patients.

Dopamine-Induced Localized Cutaneous Vasoconstriction and Piloerection

<h3>To the Editor.</h3> —Dopamine is a common drug used in the emergency department and intensive care unit settings. Previously reported cutaneous complications have included local skin necrosis due to extravasation at the site of the intravenous canula,¹and acral gangrene due to distal vasoconstriction leading to ischemia.²I report an unusual local cutaneous reaction proximal to the site of dopamine infusion. <h3>Report of a Case.</h3> —A previously healthy 27-year-old man was admitted to the coronary care unit with congestive heart failure due to idiopathic cardiomyopathy. A dopamine infusion at 5 to 7 μ/kg per minute was begun through a peripheral intravenous line in the left cephalic vein just above the wrist. Approximately 2 hours later, the patient noted an asymptomatic "rash" on the lateral side of the left upper arm, midway between the elbow and the shoulder.

541 PERCUTANEOUSLY-PLACED CENTRAL SILASTIC CATHETERS (PCSC) IN NEONATES

Complications of conventional surgically-placed central hyperalimentation catheters include caval obstruction, intracardiac thrombi and bacterial sepsis. In addition, patients require general anesthesia. We therefore have instituted in-nursery percutaneous placement of .025” o.d. Silastic catheters with the proximal tip situated within the right atrium. Ten PCSC have been placed in 8 infants weighing 880-3750 grams. Insertion sites were: right cephalic vein (3), left cephalic vein (1), right ext jugular vein (4), left ext jugular vein (2). PCSC remained in place 7-38 days. The only complication was accidental catheter dislodgement, which occurred in 3 instances (12, 16 and 20 days post-insertion). No other complications were encountered. Total cost to the patient was $268.35, compared with $791.40 for a surgically-placed central hyperalimentation line. Therefore, PCSC is an alternative to the larger bore, surgically-placed catheters, and can be inserted in the nursery without anesthesia in a small infant.

Surface characteristics of plastic intravenous catheters

The interior and exterior surfaces of four plastic, 18-gauge intravenous catheters (Abbocath-T, angiocath, Cathlon IV and Quik-Cath) were examined to identify physical characteristics that could possibly contribute to clinical thrombogenic activity. For each brand, the surface characteristics of one unused catheter (control) and a catheter placed in the left-cephalic vein of an orthopedic surgery patient for 48 hours were compared by scanning electron microscopy. All catheters had surface imperfections. Fibrinous material was found adhering to all used catheters even though exposure of the interior surfaces to blood components was minimal. It is speculated that imperfections on the surfaces of plastic i.v. catheters may contribute to thrombogenic complications in patients.

Causes of electrode dislocation with transvenous pacemaker implantation (author's transl)

The relationship between electrode dislocation and operative circumstances and case details was investigated in 486 patients who had pacemakers implanted. Electrode dislocation was more common among women and unrelated to age. The greater the operator's experience the lower the dislocation rate. Best results were obtained when implantation was performed via the left cephalic vein. There was a close relationship between threshold measurement obtained at the time of electrode placement and the frequency of dislocation.

Permanent pervenous atrial synchronized ventricular pacing.

Permanent pervenous atrial synchronized ventricular pacing was successfully accomplished in three patients. Atrial sensing was obtained from an electrode positioned in the coronary vein. Atrial electrograms with P waves greater than 1.5 mv were present in all three cases. Ventricular stimulation was accomplished through a separate electrode placed in the right ventricular apex. The left cephalic vein admitted both catheters, and the two electrodes were connected to an implantable P wave synchronized unit. The beneficial hemodynamic effects of atrial synchronized ventricular pacing were clinically evident. This new pervenous technique provides an optimal method of synchronized pacing in patients with heart block, intact sinoatrial activity and significantly compromised cardiac function.

Cardiac arrest after medication through central-venous catheter. Case report.

zine, and Scopalamine. A central-venous catheter was placed by cutdown into the left cephalic vein in the anticubital area. A second No. 14 angiocatheter was placed in a right hand vein. The anesthesia consisted of nitrous oxide, pentothal, anectine, and curare administered in the usual manner. Hypothermia was obtained with a cooling blanket. The patient was monitored with continuous EKG, esophageal thermometer, and peripheral pulse gauge. The actual surgery was uneventful except that two aneurysms (a potserior communicating aneurysm and an anterior choroidal aneurysm) were found instead of the anticipated single bilobed lesion. They were clipped uneventfully. The patient's temperature at the time of clipping was 86~ Postoperative Course. Rewarming was begun immediately and about 1�89 hours after the completion of the surgery the temperature had risen to 94~ At this point atropine 0.8 mg and neostigmine 2.5 mg were administered to reverse the curare effect. They were given successively via central-venous catheter, but in less than 1 minute there was sudden loss of EKG pattern, blood pressure, and heart sounds. External cardiac massage was immediately begun. Intravenous epinephrine and sodium bicarbonate were given via peripheral angiocatheter but there was no response. Transthoracic intracardiac epinephrine was then given with restoration of EKG, blood pressure, and peripheral pulse within a few minutes. The patient's pupils were now noted to be bilaterally fixed and dilated. A neosynephrine intravenous drip was instituted, and the patient returned to the neurosurgical intensive care unit. His temperature at this time had reached 98~ the blood pressure was 120/80, pulse rate 110, and his breathing was spontaneous and regular. The electrocardiogram now revealed a supraventricular