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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopy images during placement of a single-chamber permanent pacemaker via the right femoral vein in patient A&#46;A&#46; A Relia SR pacemaker &#40;Medtronic<span class="elsevierStyleSup">&#174;</span>&#41; in VVI mode was implanted&#44; with an 85-cm lead&#46; &#40;A&#41; Site of lead insertion in the femoral vein and position of the generator in the right flank&#59; &#40;B and C&#41; course of the lead up to the apex of the RV&#59; &#40;D&#41; lead positioned in the RV&#46; IVC&#58; inferior vena cava&#59; RV&#58; right ventricle&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Permanent pacemaker implantation via the femoral vein is an alternative for patients in whom access via the superior vena cava is impossible or contraindicated&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report two recent cases and review the technique and its indications&#44; advantages and potential complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A&#46;A&#46;&#44; an 85-year-old woman&#44; confined to bed or armchair and dependent for daily activities but with good personal relationships&#44; had a history of type 2 diabetes &#40;with diabetic nephropathy and under regular hemodialysis for nine years with a tunneled central venous catheter &#91;CVC&#93; for vascular access&#41;&#44; chronic anemia of chronic disease&#44; permanent atrial fibrillation&#44; hypertension&#44; Parkinson&#39;s disease and degenerative osteoarthritis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was medicated with insulin&#44; carbidopa-levodopa&#44; aspirin&#44; darbepoetin alfa&#44; calcium carbonate&#44; B-complex vitamins&#44; folic acid&#44; omeprazole and metoclopramide&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">She was admitted for sepsis arising from infection of the CVC in the right subclavian vein&#59; intravenous antibiotic therapy with vancomycin and gentamicin was begun&#46; <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> was subsequently isolated in blood cultures&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Replacement of the CVC was attempted&#44; but the catheter could not be moved and the patient became hemodynamically unstable&#59; it was therefore decided to leave the CVC in place and to prolong antibiotic therapy&#44; to which there was a good clinical response&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">During hospitalization&#44; periods of symptomatic atrial fibrillation with rapid ventricular rate were observed&#44; alternating with periods of slow ventricular rate&#46; A diagnosis of brady-tachycardia syndrome was therefore made&#44; and the patient was referred for permanent pacemaker implantation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography excluded significant structural heart disease&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Attempts were made to introduce the leads via the left cephalic and subclavian veins but they could not be advanced&#46; It was also impossible to obtain vascular access via the right subclavian vein due to the presence of the CVC&#46; Obstruction of the superior vena cava was documented by both fluoroscopy and computed tomography angiography &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In view of the patient&#39;s limited mobility and the absence of alternative access sites&#44; it was decided to implant a single-chamber permanent pacemaker in VVI mode via the femoral vein&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Following puncture of the right femoral vein&#44; an 85-cm active-fixation ventricular lead was advanced up to the right ventricular apex&#46; The lead was then tunneled subcutaneously to the right flank&#44; where a pocket was fashioned to house and secure the pacemaker generator &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The procedure was uneventful&#44; with good sensing and pacing parameters&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The patient was discharged with no further complications and is currently well&#46; The pacemaker is functioning normally four months after implantation&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report 2</span><p id="par0070" class="elsevierStylePara elsevierViewall">H&#46;P&#46;&#44; an 81-year-old woman&#44; partially dependent due to limited right arm mobility and osteoarthritis&#44; had a personal history of breast cancer diagnosed ten years previously and treated by right radical mastectomy&#44; radiotherapy and chemotherapy&#44; chronic lymphedema of the right arm&#44; type 2 diabetes&#44; hypertension&#44; hypothyroidism and NYHA class II heart failure&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">She was chronically medicated with oral antidiabetics&#44; statins&#44; amlodipine&#44; valsartan&#44; furosemide&#44; spironolactone&#44; levothyroxine&#44; alprazolam and betahistine&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">She was admitted for signs of decompensated heart failure and dizziness&#46; On observation&#44; she presented symptomatic bradycardia&#44; with intermittent periods of Mobitz II and complete atrioventricular block&#46; No electrolyte abnormalities or other reversible causes of bradyarrhythmia were identified&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography showed mild left ventricular systolic dysfunction &#40;previously documented&#41;&#59; analysis of wall motion were hindered by poor image quality&#44; but no other relevant alterations were observed&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The patient was referred for permanent pacemaker implantation&#46; Access via the left cephalic and subclavian veins was initially attempted but the leads could not be advanced &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Despite marked lymphedema of the right arm&#44; access via the right subclavian was also attempted but without success&#46; Angiography confirmed obstruction at the level of the superior vena cava &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">It was thus decided to implant a single-chamber permanent pacemaker via the right femoral vein&#44; the lead being tunneled subcutaneously to the right flank and a generator pocket fashioned in the abdomen &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The procedure and remaining hospital stay were uneventful and the patient was discharged two days later&#46; The pacemaker is functioning normally five months later&#44; with good sensing and pacing thresholds&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion and Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">Permanent pacemaker implantation using the femoral vein was first described in the early 1980s&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but it remains unfamiliar to most operators&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">However&#44; femoral access for transvenous temporary pacing is a frequent option&#44; due to ease of implantation and low risk of periprocedural complications&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The most common indications for transfemoral pacing are&#58; abnormalities of the venous system&#44; particularly obstruction of the subclavian vein or the superior vena cava&#59; structural alterations of the anterior thoracic wall&#44; for example following radiotherapy or mastectomy&#59; pacemaker implantation in children&#59; and the presence of multiple leads in the superior vena cava or recurrent infections of the generator pocket&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Femoral access is an effective alternative to the conventional approach&#46; Other options include venous recanalization using laser energy or surgical placement of epicardial leads&#46; However&#44; laser-assisted recanalization would carry significant risk in the cases presented due to the length of the obstructed segments and the patients&#8217; comorbidities and frailty&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The incision to introduce the leads via the femoral vein was made below the inguinal ligament in order to minimize discomfort from the scar&#46; Others&#44; such as Ellestad et al&#46;&#44; have opted to use an iliac vein approach&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">We decided in both cases to create the generator pocket in the abdominal region to avoid discomfort in the groin and thigh area with movement&#46; Creation of a generator pocket in the upper thigh&#44; an area with less subcutaneous tissue&#44; is also likely to increase discomfort and the risk of erosion&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Dislodgment of leads&#44; particularly atrial leads&#44; is a common complication of femoral or iliac vein approaches&#44; occurring in around 20&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Although not reported in the literature&#44; a higher incidence of lead fracture might be expected with this approach&#44; but this can be minimized by making a wider curve in the U-turn from the femoral vein to the generator pocket in the abdominal region&#44; allowing some slack in the subcutaneous course of the lead in order to prevent pulling when the leg is flexed&#46; Furthermore&#44; the groin is a less mobile region than the pectoral area&#44; especially in elderly patients&#44; and avoids crush injuries caused by the clavicle&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Rates of infection and deep vein thrombosis appear to be similar to the subclavian approach&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Despite the lack of studies on the subject&#44; most authors report a low rate of complications and the procedure&#44; while more surgical in nature&#44; is relatively easy to perform&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In addition to pacemaker implantation&#44; placement of cardioverter-defribillators<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a> and biventricular pacemakers<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> using the femoral approach has also been reported&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Pacemaker implantation via the femoral vein should be considered when conventional access in the pectoral region is not possible&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We describe two cases in which a permanent pacemaker was implanted via the femoral vein&#44; because the cephalic and subclavian veins were not patent&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The technique and its indications&#44; advantages and potential complications are reviewed&#46;</p>"
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      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apresentamos dois casos em que foi implantado <span class="elsevierStyleItalic">pacemaker</span> definitivo por via femoral&#44; pelo facto de n&#227;o ser poss&#237;vel faz&#234;-lo atrav&#233;s da veia cef&#225;lica ou subcl&#225;via&#46; Descrevemos a t&#233;cnica&#44; as suas indica&#231;&#245;es&#44; as vantagens e as complica&#231;&#245;es associadas&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodrigues P&#44; Reis H&#44; Lagarto V&#44; et al&#46; Implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo por via femoral&#46; Rev Port Cardiol&#46; 2014&#59;33&#58;733&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Top&#58; Initial attempt at pacemaker implantation in the first patient&#44; A&#46;A&#46;&#44; via puncture of the left subclavian vein&#44; but the guidewire could not be advanced&#46; The patient had a central venous catheter &#40;CVC&#41; in the right subclavian vein&#46; Contrast administration showed obstruction of the superior vena cava &#40;SVC&#41;&#46; Bottom&#58; computed tomography angiography images showing the CVC at the junction between the SVC and the right atrium&#44; apparently adhering to a reduced-caliber SVC&#44; which&#44; combined with the collateral circulation observed&#44; suggests secondary fibrosis of the SVC wall&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopy images during placement of a single-chamber permanent pacemaker via the right femoral vein in patient A&#46;A&#46; A Relia SR pacemaker &#40;Medtronic<span class="elsevierStyleSup">&#174;</span>&#41; in VVI mode was implanted&#44; with an 85-cm lead&#46; &#40;A&#41; Site of lead insertion in the femoral vein and position of the generator in the right flank&#59; &#40;B and C&#41; course of the lead up to the apex of the RV&#59; &#40;D&#41; lead positioned in the RV&#46; IVC&#58; inferior vena cava&#59; RV&#58; right ventricle&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopy images during attempts at pacemaker implantation in the second patient&#44; H&#46;P&#46;&#44; via the left cephalic and right subclavian veins&#44; without success&#46; Contrast administration showed obstruction of the left &#40;A and B&#41; and right subclavian veins &#40;C and D&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Single-chamber Relia SR pacemaker &#40;Medtronic<span class="elsevierStyleSup">&#174;</span>&#41; implanted via the right femoral vein in patient H&#46;P&#46; Top&#58; &#40;A&#41; lead placed in right ventricle&#59; &#40;B&#41; generator positioned in right flank&#46; Bottom&#58; photographs taken during pacemaker implantation&#44; showing incisions made in the femoral region for lead insertion and in the right flank for generator placement&#44; the subcutaneous tunneling between them&#44; and the final result&#46; RV&#58; right ventricle&#46;</p>"
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      "seccion" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Permanent pacemaker implantation via the femoral vein&#58; an alternative in cases with contraindications to the pectoral approach"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46; Mathur"
                            1 => "R&#46;H&#46; Stables"
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                        ]
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                    ]
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                        "fecha" => "2001"
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                          0 => array:2 [
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                      "titulo" => "Permanent pacemaker implantation using the femoral vein&#58; a preliminary report"
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                        0 => array:2 [
                          "etal" => false
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                            1 => "R&#46; Caso"
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                    0 => array:2 [
                      "titulo" => "Temporary transvenous pacing via the percutaneous femoral vein approach&#46; A prospective study of 100 cases"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Iliac vein approach to permanent pacemaker implantation"
                      "autores" => array:1 [
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                          "etal" => false
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