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Postoperative results of the transaxillary technique
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Background
The current indications of cardiac implantable electronic devices (CIEDs) have expanded to include young patients with serious cardiac risk factors, but CIED placement has the disadvantage of involving unsightly scarring and bulging of the chest wall. A collaborative team of cardiologists and plastic surgeons developed a technique for th...
Context in source publication
Context 1
... fossa, as it can be disguised between natural axillary creases, as long as the operator does not extend the inci- sion anteriorly beyond the anterior axillary fold. The bulge from the device is hardly noticeable, allowing the patients to continue their normal lives without continuously paying attention to the existence of the cardiac device (Fig. 5). This approach may eliminate even the small inconveniences in daily life caused by the bulge of the device when wearing a seatbelt or carrying a bag with shoulder ...
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Citations
... CIED implantation is usually performed through a horizontal incision inferior to the clavicle or an oblique incision along the deltopectoral groove. Inframammary and axillary approaches are used rarely and mainly for cosmetic reasons [5,6]. In most patients, operators opt to implant the CIED generator in a subfascial prepectoral pocket [7]. ...
Physicians are increasingly likely to encounter patients with both cardiac implantable electronic devices (CIED) and breast implants in situ. Our case indicates the importance of appropriate planning and multidisciplinary input for CIED procedures in patients with breast implants or vice versa. When planning the procedure, the aesthetic outcome needs to be considered.
... We introduced this anatomic and aesthetic placement of the VNS generator to provide a safe and cosmetically satisfying lodg- [19]. The aim was to reduce the stigma associated with the visible and often hypertrophic scar in the infraclavicular area. ...
Introduction:
Vagus nerve stimulation (VNS) is a neuromodulation therapy for drug-resistant epilepsy (DRE), refractory status epilepticus, and treatment-resistant depression. The lead is tunneled into the subcutaneous space and connected to the generator, which is usually implanted in a subcutaneous pocket below the clavicle. Surgical complications in the chest region include skin breakdown or infection. An alternative approach is to perform a subclavear subpectoral implantation. In our surgical series, we report a new aesthetic implantation method for VNS generators in children and young patients: the transaxillary subpectoral placement.
Materials and methods:
From May 2021 to May 2023, 10 vagus nerve stimulation generators were placed subpectorally with a transaxillary approach by the authors. We considered operative time, surgical complications such as blood loss, infections, device migration, pain, and adverse events at follow-up.
Results:
In this surgical series, we reviewed all cases of subpectoral implantation of VNS generators in children and young adults at our institution in the last 2 years. All patients were treated with subpectoral Sentiva 1000 (Livanova PLC) insertion with axillary access by a neurosurgeon and a pediatric surgeon. The operative time was slightly longer compared to the traditional subcutaneous implant. All generators reported impedances within the optimal range. Blood loss was not significant and no other perioperative complications were reported. Patients and families were highly satisfied with the outcomes in terms of comfort and aesthetic results after surgery and at the last follow-up. No cases of infection occurred, and no malfunctions or displacements of the generator were registered at clinical follow-up.
Conclusion:
The transaxillary subpectoral placement of theVNS generator is an aesthetic and anatomic approach, which provides several benefits to children and young adults.
... (7) To overcome this, techniques for submammary or subpectoral placement of ICDs were described by various authors. (8)(9)(10)(11) In such cases, the prominence of the ICDs would be hidden beneath the thoracic soft tissues, with more concealed incisions. Giudici et al showed that 97% of women undergoing submammary placement of ICDs felt they had made the right choice, with 95% of them suggesting that they would undergo the same procedure again and recommend it to their friends. ...
... Numerous methods for submammary or subpectoral placement of ICDs have been described, with minor differences in incision placement and plane of dissection. (8)(9)(10)(12)(13)(14) Both submammary and subpectoral methods have been proven to be effective and cosmetically acceptable by patients when compared to conventional implant placement. (8,14) More importantly, during long-term follow-up, no difference in the technical performance of the device nor the need for wound or device revision was observed with both methods of ICD placement. ...
... Secondly, a submammary plane of placement avoids the risk of causing a pneumothorax during dissection of the subpectoral pocket, although the risk of causing a pneumothorax during subpectoral placement is low, as shown by the fact that Giudici et al (8) reported only one incident of pneumothorax in his vast experience. Persichetti et al (10) and Oh et al (9) reported no pneumothoraxes in their studies; therefore, placing the ICD in a submammary plane circumvents the risk of a pneumothorax from pocket dissection. The risk of causing a pneumothorax during venous lead access remains unchanged with either plane of placement. ...
The use of implantable cardioverter defibrillators (ICDs) in young women has been increasing in recent years owing to greater awareness about inherited cardiac conditions that increase the risk of sudden death. Traditional placement of ICDs in the infraclavicular region among young women often leads to visible scars, a constant prominence that causes irritation from purse or bra straps and can result in body image concerns and device-related emotional distress. In this case series, two women with long QT syndrome required placement of ICDs for prevention of sudden cardiac death. Submammary placement of ICDs was performed in collaboration with electrophysiologists. We describe our local experience and technique in submammary placement of ICDs as well as the challenges faced.
... It is important to respect anatomical planes (i.e. between the pectoralis major and minor muscles) and not to create an intramuscular pocket to avoid undue tissue damage and bleeding (see Supplementary material online, Video S3). Submammary 25,26 and axillary 27 pockets have also been performed for cosmetic reasons but are rarely used. ...
With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.
... Cardiac implantable electronic devices (CIEDs) can be broadly divided into permanent pacemakers (PPMs), implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices. A PPM detects an irregular heartbeat (arrhythmia) and regulates the heartbeat, while an ICD is the treatment of choice for structural heart disease and symptomatic sustained ventricular tachycardia or ventricular fibrillation and also a prophylactic therapy for sudden cardiac death [1,2]. CRT devices, meanwhile, are used to improve the heart function and rate of survival, preventing sudden death in patients who show progressive heart failure despite adequate medication [3,4]. ...
... Technological advancement has reduced the size of cardiac devices, making it possible to implant them in the pectoral position, simplify the implantation procedure by avoiding the need for tunneling to the abdomen, and use them in pediatric patients. Defibrillation efficacy was also enhanced [2,10]. Pockets for the device can now be created in the axilla, abdomen, and pectoral regions. ...
... However, this technique does not account for the axillary fossa device placement. [2][3][4] Once access is obtained for the first two approaches, a 2-cm incision can be performed, taking it down to the muscularis fascia where the leads will be anchored in the usual fashion and then covering of the suture sleeves under a muscle flap should be performed, leaving the ends of the leads free. ...
Inadequate thickness of subcutaneous tissue, pectoralis muscle wasting, and/or a lack of availability of subpectoral space can become significant issues in patients with or requiring cardiovascular implantable electronic devices (CIEDs). This is particularly concerning but not exclusive in the elderly population, who may experience discomfort and hypersensitivity of the site as well as the potential for erosion and an increased risk of infection. Thus, the use of an alternative location, the axillary fossa, offers several advantages that make it a suitable option. Specifically, it usually has a preserved fat pad (even in thin patients); is unperturbed by arm movement; is not directly exposed to contact; is easily accessed with no significant compromise of neurovascular structures; and is near the conventional subclavicular sites, with enough lead length to reach in case of the need for generator replacement. Here, we present a series of five patients, including details of their anatomy and the implant techniques used. Two underwent device replacements, with one of them presenting with significant ongoing site discomfort and the other with extreme tissue thinning, respectively. Two patients with no significant fat layer or pectoral muscle wasting had new pacemakers implanted. Lastly, a biventricular implantable cardioverter-defibrillator generator was reimplanted in a younger patient who had issues with protrusion and discomfort in the setting of thin subcutaneous tissue and the subpectoral space being occupied by a large breast implant. In conclusion, the use of the axillary fossa as a new alternative CIED implantation site, using the proposed implant technique, appears feasible and safe and demonstrated excellent results related to patient comfort and adequate device cover in five cases.
... This allows implantation even in emaciated or cachexic patients or those with infection of the contralateral subclavian pocket. Further, the implantation does not particularly limit movement of the arms, which would be beneficial in younger and more active patients [6]. However, although some physicians have adapted existing techniques to treat children with limited venous access [7], it must be noted that the longevity of subcutaneous leads is not yet well established. ...
... A leadless pacemaker is a new alternative to the conventional transvenous pacemaker system to minimize CIEDs complications and some other ingenious solutions have been reported. One is submuscular implantation technique, and the other is another implantation site, such as epicardial, iliac, axillary [6], or even in supraspinatus location in patients with no prepectoral access [8]. The option of subpectoralis implant is considered when there is limited subcutaneous tissue to shield the device. ...
The number of implantations of cardiac implantable electrophysiological devices (CIEDs) has increased over the past several years. However, the aging population and expansion of indications for CIEDs have led to an increase in associated infections. We experienced a case of a 99-year-old man presenting with skin erosion at the pocket site, where a 6-month-old implantable pacemaker was replaced. He was referred for pacemaker pocket infection and presented with fever accompanied by pain and swelling around pacemaker generator. We could not explant 7-year-old pacemaker leads and the patient refused to undergo either laser lead extraction or surgical removal. We planned to re-implant in the contralateral chest. However, the patient was emaciated with low body-mass-index (15.2 kg/m²), thus concerns arose about the possibility of tissue disruption and re-infection owing to thin skin and absence of sufficient subcutaneous tissue in contralateral subclavian region. Axillary placement of CIEDs has been adopted in patients with limited venous access. We applied a mid-axillary pacemaker implant procedure to this elderly and emaciated patient. Postoperative clinical course was uneventful. After discharge, no history of unexplained fever or illness was recorded. Mid-axillary pacemaker pocket could be an alternative approach for re-implantation in patients with emaciated, cachexic, or limited pocket preparation. <Learning objective: We apply the mid-axillary pacemaker implant procedure to a nonagenarian with contralateral pacemaker infection to minimize the risk of skin disruption after implantation. This implies that implantation is possible in patients with emaciated or cachexic or infection of the contralateral subclavian pocket. Mid-axillary pacemaker pocket could be an alternative approach for re-implantation in patients with emaciated, cachexic, or limited pocket preparation.
Introduction
The implantation of a cardiac implantable electronic device (CIED) can have esthetic and psychological consequences on patients. We explore a heart team model for care coordination and discuss esthetic approaches for improved cosmetic outcomes in patients undergoing (CIED)‐related procedures or de novo implantation.
Methods
Patients undergoing CIED surgery for approved indications between June 2015 and June 2022 were identified. Patients were included when surgical care was provided by a collaborative relationship between the primary electrophysiologist and the plastic surgeon. Patient demographics, details of the surgical procedure, information on breast implants, complications, and outcomes related to cosmesis were recorded.
Results
Twenty‐two female patients were included in this study. The mean age was 50.2 ± 18.2 years. The mean follow‐up duration was 2.2 ± 5.5 months. The top two indications for the procedure included CIED generator change ( n = 9, 41%) and implantable cardioverter‐defibrillator (ICD) implantation ( n = 7, 32%). The most common reasons for involving plastic surgery in the procedure included surgery near breast implants ( n = 10, 45%) and device displacement or discomfort ( n = 8, 36%). CIED pocket position was prepectoral in 10 cases (45%), subpectoral in 11 patients (50%), and intramuscular in one patient (4.5%). The majority of the patients (20, 91%) had cosmetically acceptable results postprocedure. One patient (4.5%) had breast asymmetry on the CIED side, and another continued to have skin erosion over the CIED and leads.
Conclusion
A heart team approach incorporating the expertize of cardiac electrophysiology and plastic surgery is essential for providing optimal care for patients with breast implants and patients requesting esthetic appeal.
