Abbreviations
IJV, Internal jugular vein
LP, Leadless pacemaker
INTRODUCTION
Since the FDA’s approval of the leadless pacemaker (LP) in 2016, more than 150,000 patients have undergone LP implantation.1,2 The LP, designed to address complications linked to traditional transvenous pacemakers, has demonstrated notable reductions in major complications, such as pocket complication, pneumothorax, the need for invasive revision, and hospitalization or extension of hospital stays.2 Initially limited to single-chamber ventricular demand pacing, the LP’s technological evolution has led to the development of Micra AV, an accelerometer-based atrial sensing LP. This innovation aims to enhance atrioventricular synchrony, broadening the scope of eligible patients for implantation and representing a notable advancement in cardiac pacing technology.3,4
The devices were initially designed for introduction through the femoral vein, utilizing a large delivery sheath (27 French), but this approach raised concerns about puncture site complications. A recent study indicated a major vascular complication rate of 0.7%.5 Despite operators becoming familiar with the technique, subsequent studies showed no reduction in these complications. In addition, the femoral approach faced challenges due to the variability of femoral access and the presence of an inferior vena cava filter, making it an impractical option.6,7
Since the first reported case of LP implantation through the internal jugular vein (IJV) in 2018, the IJV has emerged as an alternative pathway.8 Herein, we present the first reported case in Taiwan where LP implantation was performed through the right IJV. This alternative approach was chosen due to recurrent pocket infection and bilateral femoral vein stenosis.
CASE REPORT
A 79-year-old man, with a medical history including end-stage renal disease, regular dialysis, liver cirrhosis, chronic obstructive pulmonary disease, and cachexia (body mass index 19.4 kg/cm2), underwent pacemaker implantation due to sick sinus syndrome. Despite recurrent pacemaker pocket infections over six months, Micra AV implantation was planned. Initial venography revealed bilateral femoral vein stenosis (Figure 1), leading to procedure termination after unsuccessful attempts to dilate the left femoral vein. Venous dissection was noted on the subsequent venography.
Figure 1.
The venography revealed bilateral femoral vein stenosis. The left panel showed tortuosity and a small lumen diameter in the right femoral vein. The right panel showed the left femoral vein with a minimal lumen diameter of 3.48 mm, which could not be dilated using a 23 French dilator. A venous dissection was observed in the subsequent venography.
With informed consent, Micra AV implantation proceeded via the right IJV under general anesthesia. Vascular ultrasound guided the 8 French sheath insertion into the right IJV. Venography ensured vessel patency, followed by sequential dilatation with 12 and 16 French dilators. The 27 French Micra introducer was placed at the junction of the superior vena cava and the right atrium. Manipulating the Micra delivery catheter through the tricuspid valve, deployment occurred in the right ventricle (Figure 2A, 2B).
Figure 2.
(A) The Micra delivery catheter was advanced across the tricuspid valve into the right ventricle (RV). (B) The Micra AV pacemaker was successfully deployed at the low septum of the RV.
Favorable pacing parameters (the capture threshold 0.5 V and R wave 5.2 mV) were noted during the examination and the LP position was confirmed with a chest X-ray. Hemostasis and wound closure were achieved with a figure-of-8 suture, avoiding complications such as hematoma.
DISCUSSION
To our knowledge, this was the first case that underwent LP implantation through the IJV in Taiwan. Although it took time for general anesthesia and pre-procedure preparation, the entire process of LP implantation did not take more time than the femoral route approach. Remarkably, the procedure exhibited a lack of periprocedural or delayed complications, affirming its safety.
Although our case is not the first Micra AV implantation through the IJV in Asia, it highlights several important points. First, despite our patient being classified as high-risk according to the scoring system developed by Piccini et al., the procedure was completed smoothly without any complications.9 Given the IJV’s superficial positioning in contrast to the deeper femoral vein, achieving hemostasis is considerably easier, even when employing a large-caliber sheath. Second, as mentioned by Saleem-Talib, Shmaila, et al., delivering the device to the right ventricle through the IJV was even easier than via the femoral vein due to the curvature of the delivery system.10
It allows for a more direct trajectory course leading to the right ventricle, and thus, it is easier to cross the tricuspid valve. The Micra delivery system tends to be easily manipulated. Lastly, the opposite curvature of the delivery system allows for minimal deflection to avoid the tip of the device from pointing towards the right ventricular apex and the inferior wall, where perforation can occur and lead to pericardial effusion.
The first cohort study in 2022 focusing on the safety and feasibility of LP implantation via the IJV reported no puncture site-related complications, including hematoma, arteriovenous fistula, or aneurysm, among 82 patients.10 These results revealed that puncture site complications were lower via the IJV than the femoral vein. Additionally, the jugular vein approach also facilitates the implantation position at the right ventricular outflow tract of the right ventricular mid-septum, which seems to have a narrow QRS duration.
The PACES study also supports the feasibility and safety of LP implantation through the jugular vein, especially in pediatric patients with lower body weight.11 Notably, accessing the right or left IJV in pediatrics yielded no reported puncture site complications. Table 1 below demonstrates the procedure and related outcomes of the IJV approach.
Table 1. Comparison between procedures performed through the internal jugular vein and the femoral vein.
| Vessel diameter12,13 | Threshold | Sensed R wave amplitude | Impedance | Puncture site complications | Fluoroscopy time | Successful rate | Ambulation | |
| IJV | 10-12 mm | 0.44 V | 11 mV | 585 ohms | 0% | 4.4 min | 100% | Immediate |
| FV | 8.5-10 mm | 0.5V-0.6 V | 11.4 mV | 572 ohms | 0.75% | 8-12 min | 99.6% | Need bed rest due to groin approach |
All the data about the IJV approach were based on a single cohort study, and there was no head-to-head comparison between procedures performed through different routes.10 The results concerning the femoral vein approach were based on several cohort studies.2,14 The IJV approach seems more suitable for patients with an IVC filter, femoral vein stenosis, anatomical variations, and has been proven safe in children with low body weight (< 30 kgs).11
FV, femoral vein; IJV, internal jugular vein.
This was the first time we conducted an LP implantation using the IJV approach. There are several important considerations and strategies to keep in mind. First of all, the procedure was performed from the head side, necessitating a table at the patient’s head to provide extra support for the LP delivery system. Secondly, because the delivery catheter was designed for a femoral vein approach, it provides a small angle toward the septum wall. When using the IJV approach, it’s crucial to avoid excessive deflection of the delivery catheter. Excessive deflection can cause the catheter to veer toward the free wall after crossing the tricuspid annulus, potentially complicating the procedure. During the procedure, we found it easier to manipulate the delivery system and select a non-apical position.
In conclusion, our successful LP implantation through the IJV approach not only validates the safety of the procedure but also highlights its practical application, particularly beneficial for a fragile patient with unfavorable femoral venous approach.
DECLARATION OF CONFLICT OF INTEREST
All the authors declare no conflict of interest.
IRB/ERB NUMBER AND DATE OF APPROVAL
This study received approval from the institutional review board of Tri-Service General Hospital (IRB No. A202315092; date of approval: 2023/5/30).
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