1. CIED implant
trouble shoot in
cath room
台北榮民總醫院
護理師 郭宜蘭

2. Venogram
Subclavian vein
cephalic vein

3. Acute Venous Stenosis
Limiting Access

4. Implantation Techniques
- Acute
 Pneumothorax
 Hemothorax
 Pneumo- hemothorax
 Brachial plexus injury
 Arterial puncture
 Chylothorax
 Infection
 Pocket Hematoma / Seroma

5. Pneumothorax
In PASE Trial: 1.97%

6. Management for
Pneumothorax
 withdraw the needle, wait a moment or two to make
certain that a rapid-onset, large, markedly
symptomatic pneumothorax is not occurring, and
then proceed
 If a pneumothorax does develop, it may do so in this
setting over a matter of hours and may not even be
apparent radiographically at the end of the procedure.
 If a lung puncture has occurred, obtaining another
upright chest radiograph 6 hours after completion of
the procedure is advisable. If a pneumothorax has
developed, a chest tube or catheter evacuation
procedure may be necessary, although frequently,
a small to moderate pneumothorax that is not
expanding can be managed conservatively without
evacuation.

7. Avoid air embolism (esp.
for large-bored sheaths)
press proximal end of sheath
and instruct patient to hold
breath during pacing lead
insertion
use of introducer sheath with
hemostatic valve

8. Myocardial Perforation
 When recognized,
lead MUST be
pulled back
 Be prepared for
tamponade
 May require open
procedure to
manage but heart
usually seals itself.

9. Diaphragmatic Stimulation
Lead in Cardiac Vein
Lead inadvertently placed into Post.Cardiac V

10. Management of Pocket
Hematoma
 Observation and close follow-
up
– Soft
– Minimal to no tenderness
 Surgical evacuation
– Tense pocket threatening suture
line
– Weeping suture line
– Severe pain
– Immunocompromised host

11. Causes of Open Circuit
Due to Implant Technique
 Loose set screw
 Improperly seated lead
terminal pin
 Conductor fracture
– Rib Clavicle Crush
– Tight ligature
 “Dry” pocket - air in pocket
with unipolar configuration
– Replacement

12. Pulse Generator Pocket
Chronic
 Pain - pocket neuralgia
– Incorrect tissue plan
– Incorrect location - too lateral
– Smoldering infection
 Erosion
– Pressure necrosis
– Smoldering infection
 Migration
 Twiddler’s Syndrome

13. Pressure Necrosis
Thinning and discoloration
at lateral margin
Total breakdown and 2°
Infection

16. Smoldering Pocket
Infection with draining
fistula
 Presented 2 years
post implant
 Eschar and
draining fistula at
edge of incision,
surrounding
erythema
 Waxed and waned
on oral antibiotics
 Local cultures were
negative January 24, 2002

17. Improper Location of
Pulse Generator
If the
pacemaker is
placed too
lateral, it will
cause
discomfort every
time the patient
rotates arm
forward

18. Loose Anchoring Sleeve
Twiddler’s Syndrome

19. Conductor Fractures
 Occurs at stress points
– Rib-Clavicle Crush
– Tight Anchoring sleeve
ligature
– Angulation of lead
– Traction on lead
 If external conductor of
bipolar lead, conversion to
unipolar will allow for
elective management

20. Tight Anchoring Sleeve
Damage to Lead

22. Conductor Coil Fracture

23. Insulation Damage

24. Thanks for your listening:)
See you next time.
It’s time to wake up!!