Supraclavicular course of the cephalic vein — implications for cardiac electronic device implantation

Abstract

Cephalic vein (CV) cut-down within the clavipectoral triangle is typically the first choice in transvenous lead placement, which is due to its lower risk of injury to neighbouring structures than with axillary vein (AV) puncture. However, it is only with favourable morphometric parameters of the CV that cardiac leads can be successfully passed through subsequent vessels, such as the AV and the subclavian vein (SV). We present a rare CV variation detected during cardiac pacing device implantation. After a cardiac lead was partially introduced into the venous system via the CV cut-down approach during a VVI device implantation in a 71-year-old male, there was a problem with advancing it further. Fluoroscopy revealed a supraclavicular course of the lead and the site of blockage. Intravenous contrast administration showed the cause of the problem by fully visualizing the morpho-anatomical venous layout: CV bifurcated into two vessels, the larger one of which traversed above the clavicle and the smaller one had an infraclavicular course typical for the CV and ultimately drained into the SV. Eventually, the lead was introduced via the infraclavicular branch of the vessel and connected to the pacemaker after optimal pacing parameters had been achieved. Six out of 1828 cases (0.3%) of first-time procedures for cardiac pacing device implantation conducted at our clinic between 2011 and 2014 showed the variation presented here, i.e. CV bifurcation with one of the resulting vessels coursing above the clavicle.

Transvenous lead insertion via a supraclavicular CV branch may result in lead damage (insulation) as well as overlying tissue injury (skin), which should be taken into account as late complications of cardiac pacing device implantation. Any atypical course of transvenous leads requires intra-procedural fluoroscopy with diagnostic administration of a contrast agent to visualize morphometric parameters of vessels including such findings as CV with a supraclavicular branch. A supraclavicular course of the CV is a rare anatomical phenomenon; however, it may have a significant impact on transvenous placement of pacemaker or defibrillator leads.