Subcutaneous implantable cardioverter-defibrillator implantation in a patient with an axillary bifemoral bypass and past sternectomy

Figures

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  Figure 1. A: Upper panel: ventricular tachycardia recorded by an ambulatory monitor. Lower panel: the initiation of a recurrence after admission. B: Postoperative computed tomography scan in the short-axis view depicting the defective sternum refilled by the omental flap, as highlighted by the red circle, and prosthetic graft, shown by the red arrow. C: Three-dimensional reconstruction of the major arteries revealing the axillary femoral bypass graft appearing in the left first intercostal space and located along the midclavicular line (red arrows).

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  Figure 2. A: Preoperative marking showing the predetermined location of the pulse generator and lead. B: Picture of the insertion of an 11F peel-away sheath under the prosthetic graft (dotted line) using straight pean forceps in the direction of the red arrow, which is in the direction from the generator pocket to the mid-incisional line. C: Posteroanterior chest radiograph after implanting the subcutaneous cardioverter-defibrillator with the lead located in the left parasternal position.

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  Figure 3. A: Postoperative plain computed tomography scan image confirming the lead placed on the edge of the ribs without sticking into the omental flap as shown by the red arrow. B: Electrogram tracing from the substernal lead showing an appropriate R-wave amplitude in all of the 3 vectors. C: Successful defibrillation test performed with a single 65 J shock after ventricular fibrillation induction with a 50 Hz stimulation.