Placement of pacemaker leads via the extrathoracic subclavian vein guided by fluoroscopy and venography in the oblique projection.

Blind needle puncture of the subclavian vein, which is the standard method used for insertion of pacemaker electrodes, causes an increased risk of lead fractures due to entrapment of the lead by the costoclavicular ligament and/or subclavius muscle. The extrathoracic lead insertion technique was developed to prevent such lead fractures. The present study was performed to evaluate the usefulness of extrathoracic subclavian vein puncture under the guidance of both fluoroscopy and venography in the oblique beam projection. Pacemaker leads were implanted in ten patients under the guidance of both fluoroscopy and venography in the ipsilateral anterior oblique projection. The angle of projection was set as large as possible between 35 degrees and 45 degrees . The needle was held parallel to the X-ray angle of incidence and inserted toward the first rib, then withdrawn until the tip entered the subclavian vein. This modified method of pacemaker implantation was successful in all patients, with no complications during the follow-up period ranging from 4 to 19 months. It also prevented pneumothorax and lead entrapment in soft tissue associated with the clavicle that might be caused by the conventional technique.