In the past several decades there has been a continuous growth in the field of cardiac implantable electronic devices (CIED) implantation procedures as well as their technological development. CIEDs utilize transvenous leads that are introduced into the heart via the axillary, subclavian, or cephalic veins, as well as a devices generator that is implanted in a subcutaneous pocket, typically in the pre-pectoral region. Despite this significant improvement, complication rates range from 1-6% with current implant tools and techniques. In this review we will discuss the three central parts of the CIED implantation procedure, their impact on implantation site, infections, and possibilities for its prevention.
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Pacemakers (PM), implantable cardiac defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices are life-saving treatments for many cardiac conditions [
In this review, we will discuss the differences between different currently used CIED implantation approaches and techniques. In order for better understanding, we focused our attention on three specific parts regarding the CIEDs implantation process, which is associated with the majority of the procedural complications and hopefully can help in their prevention.
Incision sites
CIED implantations are most often performed in the left sub-pectoral region. During this procedure a small 2.5-3.5cm incision is made. There are two most commonly used incision sites during CIED implantation procedures. The first type of incision is inferior and parallel to the clavicle, placed in the triangle over the anterior chest from the shoulders to the xiphoid line; this is called “infraclavicular” or C-type incision. The second type of incision is along the deltopectoral groove; “deltopectoral” D-type incision [
The infraclavicular or C-type incision provides access to both the cephalic vein when a cut-down technique is used and the subclavian vein (puncture technique) and it is used for either subcutaneous or subpectoral pocket formation. However, this access site can be very challenging for performing the cephalic vein cut-down and axillary vein puncture technique. In comparison, the deltopectoral D-type incision is made approximately 2 cm below the clavicle, in the deltopectoral groove (indentation between the clavicular head of the pectoralis major medially and the deltoid laterally). Because this incision type runs along the cephalic vein, it allows a much simpler way to explore the cephalic cut-down technique. This D-type incision also provides easier and unique access to the axillary vein (puncture technique). This type may limit access to the subclavian vein (puncture technique) and the pocket needs to be made medially to the incision site [
This first part of our journey, called CIED implantation procedures and techniques, regarding the incision site, is in favor of deltopectoral D-type of incision, due to the easier access to the cephalic and axillary vein. If we agree that the cephalic vein cut-down technique and axillary vein puncture technique are two of three widely used main lead access sites, we can conclude that deltopectoral D-type incision is more favorable over the infraclavicular C-type incision. Regarding the scarring, comparing booth incision sites, deltopectoral D-type is probably preferable, but as we concluded additional clinical trials are needed to prove this point.
Central venous access
Gaining central venous access is a central part of the implantation procedure of CIEDs. However, there are no strict recommendations about the first access site choice, so in practice, this decision depends on operator preference and experience [
Wound closure and antibiotic envelope experiences
With the advancement in technology and widespread accessibility to CIEDs around the world, an entity called CIED-related infections emerged. The incidence of these infections over the past decade was estimated at 1% to 4%, including all device implantations, despite the use of well-known prophylactic strategies such as pre-operative antibiotics and sterile surgical techniques, leading to significant morbidity, mortality, and enormous cost to the health care system [
Over the years CIED implanters have explored different suture techniques in order to minimize pocket infections, and the results suggest that suture technique does not alter PM generator pocket infection rate. Also, pocket toileting by antibiotics does not have a role in PM pocket infection rate. According to European Heart Rhythm Association (EHRA) recommendations, pocket hemostasis is the most important factor for prevention of PM pocket infection as well as proper surgical asepsis practice and the use of preoperative antibiotics [
To address these concerns, and with the aim of reducing CIED related infections, a multifilament mesh envelope that elutes two antibiotics, rifampin and minocycline, was approved by the Food and Drug Administration (FDA) in 2008 for CIED stabilization [
Incision site, central venous access, and wound closure are only parts of the big puzzle of CIED implantation procedures and techniques. The incision site is probably, like every other part of this brief review, associated with the strategies of the selected device implantation center, learning process, and experiences. Incision type D is more efficient over the infraclavicular C-type, when cephalic vein cut-down or axillary vein puncture is the targeted technique for gaining central venous access. This incision site is also connected with less local scarring. Various centers have different strategies regarding the central access vein for CIED lead placement. It is definite that in the majority of cases, the cephalic vein cut-down technique is getting less attention, probably because it's often more time-consuming and has a longer, more difficult learning curve. Subclavian vein puncture technique is widely used, considering it is easy to perform especially with several useful tips and tricks like preprocedural/procedural contrast-enhanced venogram, anatomical markers, ultrasound-guided, and many others. But due to the most common complications connected with this puncture technique, axillary vein puncture is getting its rightful place in the process of choosing the right technique for central venous access. In addition to wound closure, the use of an antibiotic envelope in selective patients can be very helpful in prevention of CIED implantation infections, especially in high-risk patients. Hopefully this focused review will provide an additional summary of evidence and data to reduce the percentage of infections from these procedures.
The authors have declared that no competing interests exist.