LAUSR

A 42-year-old man presenting with fatigue was admitted for pacemaker replacement. His ECG showed third degree atrioventricular block and bradycardia. Nine years before, he received the Glenn operation and single-chamber pacemaker implantation due to third degree atrioventricular block postoperation. The pacemaker leadwas via right subclavian vein to right pulmonary artery, and then inserted at the right ventricle outflow tract. During the pacemaker replacement procedure, the prior ventricular leadwasmalfunctioning and the new lead could not pass through the stenosis located at the junction between pulmonary artery and superior vena cava. Thus, the routine access for pacemaker lead was not available. A dual-chamber pacemaker was planned to be implanted using the percutaneous trans-hepatic venous approach. An angiography of peripheral hepatic vein was performed via the inferior vena cava and a guide wire was placed in the target vein chosen as leads access. The peripheral hepatic vein was punctured and 2 guide wires were advanced into the right atrium (Fig. 1). An 8F peel-away sheath was advanced into hepatic vein. A ventricular lead was advanced through the sheath into the functional right ventricle and inserted in the apex. Through the second wire, another sheath was introduced and the atrial lead was inserted in the right atrium. Both leads were curved in the right atrium to avoid tautness. The generator was buried in a created pocket in the abdominal wall anterior to the rectus abdominis behind the rectus sheath (Fig. 2A). After the procedure, ultrasound examination excluded local liver injury, hematoma and hepatic vein thrombosis. The ECG showed a pacing rhythm in DDD mode (Fig. 2C). At the 2-month followup, radiograph showed the ventricular lead still had the same shape and position to that just after the procedure and the atrial lead shape changed a little but without dislocation (Fig. 2B). No discomfort and no dysfunction of liver were observed during our 1-year followup. Pacemaker programming showed normal sensitivity and capture threshold. F IGURE 1 Punctureof peripheral hepatic vein under the guidanceof angiography