Femoral access-guided multi-site ICD implantation: a single-center experience in 903 cases from northeast brazil
A Aurelio Marinho Rosa Filho, R Fonseca Oliveira Suruagy Motta, M C De Souza Xavier, L Brandao Cavalcante, T Jose De Souza Xavier, M L Batista Silva, S Cavalcante Juca Nogueira Falcao, J M De Almeida Ferreira Neto, L Vasconcelos De Sousa Torres, J Francisco Silva, E Ferreira Xavier JuniorAbstract
Background
Multisite Implantable Cardioverter-Defibrillator (ICD+CRT) therapy is the established treatment for patients with dilated cardiomyopathy, Left Bundle Branch Block (LBBB), and Ventricular Tachycardia (VT). However, procedure time can be extended due to difficulties navigating to the Coronary Sinus (CS).
Objectives
To present our extensive experience in 903 cases utilizing the femoral vein puncture as a guide to facilitate the subsequent approach and sheath insertion into the subclavian vein for CS lead placement.
Methodology: Between March 2010 and August 2025, 903 patients received ICD+CRT implants. The cohort predominantly consisted of men (590 patients, 65%). These patients presented with refractory Heart Failure (HF), an Ejection Fraction (EF 35%), LBBB, and VT. In this series, the CS access was achieved via the femoral approach. Immediate success was defined by QRS narrowing; thus, all patients underwent femoral vein puncture and the introduction of a quadripolar catheter into the CS. This initial catheter served as a guide for the subsequent insertion of a second quadripolar catheter inside the sheath, easily directing it to the CS. This allowed for a venogram and the selection of the ideal vein for Left Ventricular (LV) electrode placement.
Results
The procedure was highly successful, with 99.8% of cases achieving CS access without major complications such as perforation, rupture, or tamponade. Clinically, 74% of patients experienced QRS complex narrowing, with a mean duration of 110ms. Late postoperative lead dislodgement of the LV electrode occurred in only four patients (0.44%), managed in a secondary procedure. Eight patients (0.88%) required implantation via the right subclavian vein, and four (0.44%) had a persistent Left Superior Vena Cava (LSVC). Immediate postoperative phrenic nerve stimulation occurred in 30 patients (3.32%), which was successfully managed by reprogramming pacing parameters. The average procedure time, from femoral puncture to pocket closure, ranged from 1 hour 20 minutes to 2 hours 30 minutes, with a mean of just 1h and 30 minutes.
Conclusion
The adoption of the femoral access technique to guide the subclavian sheath introduction effectively reduced the overall procedure time to a low average of 1h 30 minutes, consequently leading to a reduction in ionizing radiation exposure for both the patient and the clinical team.