Long‐term reliability of the defibrillator lead inserted by the extrathoracic subclavian puncture

Background As the transvenous defibrillator lead is fragile and its failure may cause a life‐threatening event, reliable insertion techniques are required. While the extrathoracic puncture has been introduced to avoid subclavian crush syndrome, the reports on the long‐term defibrillator lead survival using this approach, especially the comparison with the cephalic cutdown ( CD ), remain scarce. We aimed to evaluate the long‐term survival of the transvenous defibrillator lead inserted by the extrathoracic subclavian puncture ( ESCP ) compared with CD . Methods Between 1998 and 2011, 324 consecutive patients who underwent an implantable cardioverter‐defibrillator ( ICD ) implantation in Hokkaido University Hospital were included. ICD leads were inserted by CD from 1998 to 2003 and by contrast venography‐guided ESCP thereafter. Lead failure was defined as a nonphysiologic high‐rate oversensing with abnormal lead impedance or highly elevated sensing and pacing threshold. Results Of 324 patients, CD was used in 37 (11%) and ESCP in 287 patients (89%). During the median follow‐up of 6.2 years ( IQR :3.2‐8.3), 7 leads (2 in CD and 5 leads in ESCP group) failed. All patients with lead failure in ESCP group were implanted with either SJM Riata (n = 1) or Medtronic Fidelis lead (n = 4). Five‐year lead survival was 93.8% ( CI 95%:77.3‐98.4%) in CD compared with 99.1% ( CI 95%:96.6‐99.8%) in ESCP group ( P = 0.903). Univariate Cox regression analysis showed that the use of Fidelis or Riata lead was the strong predictor of the ICD lead failure ( HR 13.8, CI 95%:2.9‐96.5; P = 0.001). Conclusions Contrast venography‐guided extrathoracic puncture ensures the reliable long‐term survival in the transvenous defibrillator leads.