Surgical options for endocardial lead placement when upper veins are obstructed or nonusable

In 35 patients (24 adults, 11 children), two techniques were used to implant endocardial pacemaker or defibrillator leads in the presence of complete occlusion or nonusability of upper veins. The obstructed veins were the subclavian, innominate, and superior vena cava (SVC). Most of the obstructions occurred secondary to previous implant of multiple leads. Twenty-four patients had occlusion of the subclavian veins; 7 of both the subclavians and innominates; 4 had stenosis of the SVC. Twenty-seven patients with obstructed subclavian veins, but with patent innominates, underwent direct implants via cut-down internal jugular vein for one or two leads, as needed. Eight patients with obstructed innominate veins or SVC underwent a direct transthoracic transatrial approach (TTTA). This method involves a parasternal extrapleural route through the mediastinum to directly puncture the right atrium. The leads are then implanted endocardially, under fluoroscopy. There were no complications with either method, and the implanted units have been working well during up to 14 years follow-up. These two techniques circumvent the problem of obstructed upper veins--which limits the options for implanting endocardial pacing systems.