array:25 [
  "pii" => "S2174204914002542"
  "issn" => "21742049"
  "doi" => "10.1016/j.repce.2014.05.005"
  "estado" => "S300"
  "fechaPublicacion" => "2014-11-01"
  "aid" => "528"
  "copyright" => "Sociedade Portuguesa de Cardiologia"
  "copyrightAnyo" => "2014"
  "documento" => "simple-article"
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "crp"
  "cita" => "Rev Port Cardiol. 2014;33:733.e1-6"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 6003
    "formatos" => array:3 [
      "EPUB" => 191
      "HTML" => 5114
      "PDF" => 698
    ]
  ]
  "Traduccion" => array:1 [
    "pt" => array:19 [
      "pii" => "S0870255114002261"
      "issn" => "08702551"
      "doi" => "10.1016/j.repc.2014.05.004"
      "estado" => "S300"
      "fechaPublicacion" => "2014-11-01"
      "aid" => "528"
      "copyright" => "Sociedade Portuguesa de Cardiologia"
      "documento" => "simple-article"
      "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
      "subdocumento" => "crp"
      "cita" => "Rev Port Cardiol. 2014;33:733.e1-6"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 7242
        "formatos" => array:3 [
          "EPUB" => 202
          "HTML" => 6004
          "PDF" => 1036
        ]
      ]
      "pt" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Caso Cl&#237;nico</span>"
        "titulo" => "Implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo por via femoral"
        "tienePdf" => "pt"
        "tieneTextoCompleto" => "pt"
        "tieneResumen" => array:2 [
          0 => "pt"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "733&#46;e1"
            "paginaFinal" => "733&#46;e6"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Permanent pacemaker implantation using a femoral approach"
          ]
        ]
        "contieneResumen" => array:2 [
          "pt" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "pt" => true
        ]
        "contienePdf" => array:1 [
          "pt" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0020"
            "etiqueta" => "Figura 4"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr4.jpeg"
                "Alto" => 2693
                "Ancho" => 2917
                "Tamanyo" => 449261
              ]
            ]
            "descripcion" => array:1 [
              "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Pacemaker</span> de c&#226;mara &#250;nica&#44; Relia SR &#40;Medtronic<span class="elsevierStyleSup">&#174;</span>&#41;&#44; implantado pela veia femoral direita na doente H&#46; P&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Em cima&#58;</span> A&#58; el&#233;trodo colocado no ventr&#237;culo direito &#40;VD&#41;&#46; B&#58; posicionamento do gerador no flanco direito&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Em baixo&#58;</span> fotografias durante a implanta&#231;&#227;o do <span class="elsevierStyleItalic">pacemaker</span>&#44; nomeadamente das incis&#245;es feitas a n&#237;vel femoral &#40;local de inser&#231;&#227;o do eletrocateter&#41; e no flanco direito &#40;onde foi colocado o gerador&#41;&#44; bem como da tuneliza&#231;&#227;o subcut&#226;nea feita entre elas e o resultado final&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Patr&#237;cia Rodrigues, Hip&#243;lito Reis, V&#237;tor Lagarto, Paulo Palma, Carla Roque, Ant&#243;nio Pinheiro&#8208;Vieira, Diana Anjo, Severo Torres"
            "autores" => array:8 [
              0 => array:2 [
                "nombre" => "Patr&#237;cia"
                "apellidos" => "Rodrigues"
              ]
              1 => array:2 [
                "nombre" => "Hip&#243;lito"
                "apellidos" => "Reis"
              ]
              2 => array:2 [
                "nombre" => "V&#237;tor"
                "apellidos" => "Lagarto"
              ]
              3 => array:2 [
                "nombre" => "Paulo"
                "apellidos" => "Palma"
              ]
              4 => array:2 [
                "nombre" => "Carla"
                "apellidos" => "Roque"
              ]
              5 => array:2 [
                "nombre" => "Ant&#243;nio"
                "apellidos" => "Pinheiro&#8208;Vieira"
              ]
              6 => array:2 [
                "nombre" => "Diana"
                "apellidos" => "Anjo"
              ]
              7 => array:2 [
                "nombre" => "Severo"
                "apellidos" => "Torres"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "pt"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2174204914002542"
          "doi" => "10.1016/j.repce.2014.05.005"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002542?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114002261?idApp=UINPBA00004E"
      "url" => "/08702551/0000003300000011/v1_201411200056/S0870255114002261/v1_201411200056/pt/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2174204914002670"
    "issn" => "21742049"
    "doi" => "10.1016/j.repce.2014.04.006"
    "estado" => "S300"
    "fechaPublicacion" => "2014-11-01"
    "aid" => "543"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "simple-article"
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "crp"
    "cita" => "Rev Port Cardiol. 2014;33:735&#46;e1-5"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3474
      "formatos" => array:3 [
        "EPUB" => 181
        "HTML" => 2708
        "PDF" => 585
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Intravenous leiomyomatosis&#58; A rare cause of intracardiac mass"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "pt"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "735&#46;e1"
          "paginaFinal" => "735&#46;e5"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Leiomiomatose intravascular&#58; uma causa rara de massa intra-card&#237;aca"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 1420
              "Ancho" => 1752
              "Tamanyo" => 232570
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Enhanced computed tomography scan&#46; Coronal &#40;left&#41; and sagittal &#40;right&#41; sections showing a filling defect image extending from the right atrium through the inferior vena cava &#40;white arrow&#41;&#46; A well-defined tumor arises from the uterus &#40;black arrow&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "In&#234;s Cruz, Isabel Jo&#227;o, Bruno Stuart, M&#225;rio Iala, Lu&#237;sa Bento, Carlos Cotrim, &#194;ngelo Nobre, H&#233;lder Pereira"
          "autores" => array:8 [
            0 => array:2 [
              "nombre" => "In&#234;s"
              "apellidos" => "Cruz"
            ]
            1 => array:2 [
              "nombre" => "Isabel"
              "apellidos" => "Jo&#227;o"
            ]
            2 => array:2 [
              "nombre" => "Bruno"
              "apellidos" => "Stuart"
            ]
            3 => array:2 [
              "nombre" => "M&#225;rio"
              "apellidos" => "Iala"
            ]
            4 => array:2 [
              "nombre" => "Lu&#237;sa"
              "apellidos" => "Bento"
            ]
            5 => array:2 [
              "nombre" => "Carlos"
              "apellidos" => "Cotrim"
            ]
            6 => array:2 [
              "nombre" => "&#194;ngelo"
              "apellidos" => "Nobre"
            ]
            7 => array:2 [
              "nombre" => "H&#233;lder"
              "apellidos" => "Pereira"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S0870255114002583"
        "doi" => "10.1016/j.repc.2014.04.005"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114002583?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002670?idApp=UINPBA00004E"
    "url" => "/21742049/0000003300000011/v1_201412120159/S2174204914002670/v1_201412120159/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2174204914002530"
    "issn" => "21742049"
    "doi" => "10.1016/j.repce.2014.06.003"
    "estado" => "S300"
    "fechaPublicacion" => "2014-11-01"
    "aid" => "517"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2014;33:727-32"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3859
      "formatos" => array:3 [
        "EPUB" => 170
        "HTML" => 2791
        "PDF" => 898
      ]
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Evidenced-Based Cardiology</span>"
      "titulo" => "What is the effect on cardiovascular events of reducing hyperuricemia with allopurinol&#63; An evidence-based review"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "pt"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "727"
          "paginaFinal" => "732"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Qual o efeito da redu&#231;&#227;o da hiperuricemia nos eventos cardiovasculares&#63; Revis&#227;o baseada na evid&#234;ncia"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Marta Guedes, Ana Esperan&#231;a, Ana Cristina Pereira, Catarina Rego"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Marta"
              "apellidos" => "Guedes"
            ]
            1 => array:2 [
              "nombre" => "Ana"
              "apellidos" => "Esperan&#231;a"
            ]
            2 => array:2 [
              "nombre" => "Ana Cristina"
              "apellidos" => "Pereira"
            ]
            3 => array:2 [
              "nombre" => "Catarina"
              "apellidos" => "Rego"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "pt" => array:9 [
        "pii" => "S0870255114001991"
        "doi" => "10.1016/j.repc.2014.06.002"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "pt"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114001991?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002530?idApp=UINPBA00004E"
    "url" => "/21742049/0000003300000011/v1_201412120159/S2174204914002530/v1_201412120159/en/main.assets"
  ]
  "asociados" => array:1 [
    0 => array:20 [
      "pii" => "S2174204915000793"
      "issn" => "21742049"
      "doi" => "10.1016/j.repce.2014.12.002"
      "estado" => "S300"
      "fechaPublicacion" => "2015-05-01"
      "aid" => "629"
      "copyright" => "Sociedade Portuguesa de Cardiologia"
      "documento" => "simple-article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
      "subdocumento" => "cor"
      "cita" => "Rev Port Cardiol. 2015;34:367-8"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 3868
        "formatos" => array:3 [
          "EPUB" => 145
          "HTML" => 3076
          "PDF" => 647
        ]
      ]
      "en" => array:11 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
        "titulo" => "Dual chamber permanent pacemaker implantation by femoral approach"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "367"
            "paginaFinal" => "368"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "pt" => array:1 [
            "titulo" => "Implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo dupla c&#226;mara por via femoral"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figure 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 2575
                "Ancho" => 3000
                "Tamanyo" => 412801
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Incision in the right groin&#44; below the inguinal ligament&#59; &#40;B&#41; advancing the 110-cm CapSureFix<span class="elsevierStyleSup">&#174;</span> Novus 4076 bipolar ventricular lead via the inferior vena cava&#59; &#40;C&#41; positioning and active fixation of the ventricular lead in the right ventricular apex&#59; &#40;D&#41; advancing the 85-cm CapSureFix<span class="elsevierStyleSup">&#174;</span> Novus 5076 bipolar atrial lead via the inferior vena cava&#59; &#40;E&#41; positioning and active fixation of the atrial lead in the right atrial appendage&#59; &#40;F&#41; implantation of the generator in a pocket in the subcutaneous tissue of the right iliac fossa&#59; &#40;G&#41; right groin after suturing of the pocket&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Gustavo Lima da Silva, Pedro Marques"
            "autores" => array:2 [
              0 => array:2 [
                "nombre" => "Gustavo"
                "apellidos" => "Lima da Silva"
              ]
              1 => array:2 [
                "nombre" => "Pedro"
                "apellidos" => "Marques"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "pt" => array:9 [
          "pii" => "S0870255115000797"
          "doi" => "10.1016/j.repc.2014.12.004"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "pt"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255115000797?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915000793?idApp=UINPBA00004E"
      "url" => "/21742049/0000003400000005/v1_201506091454/S2174204915000793/v1_201506091454/en/main.assets"
    ]
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
    "titulo" => "Permanent pacemaker implantation using a femoral approach"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "733&#46;e1"
        "paginaFinal" => "733&#46;e6"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Patr&#237;cia Rodrigues, Hip&#243;lito Reis, V&#237;tor Lagarto, Paulo Palma, Carla Roque, Ant&#243;nio Pinheiro-Vieira, Diana Anjo, Severo Torres"
        "autores" => array:8 [
          0 => array:4 [
            "nombre" => "Patr&#237;cia"
            "apellidos" => "Rodrigues"
            "email" => array:1 [
              0 => "pfdrodrigues&#64;gmail&#46;com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "Hip&#243;lito"
            "apellidos" => "Reis"
          ]
          2 => array:2 [
            "nombre" => "V&#237;tor"
            "apellidos" => "Lagarto"
          ]
          3 => array:2 [
            "nombre" => "Paulo"
            "apellidos" => "Palma"
          ]
          4 => array:2 [
            "nombre" => "Carla"
            "apellidos" => "Roque"
          ]
          5 => array:2 [
            "nombre" => "Ant&#243;nio"
            "apellidos" => "Pinheiro-Vieira"
          ]
          6 => array:2 [
            "nombre" => "Diana"
            "apellidos" => "Anjo"
          ]
          7 => array:2 [
            "nombre" => "Severo"
            "apellidos" => "Torres"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Servi&#231;o de Cardiologia&#44; Centro Hospitalar do Porto&#44; Porto&#44; Portugal"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo por via femoral"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2917
            "Ancho" => 2917
            "Tamanyo" => 577690
          ]
        ]
        "descripcion" => array:1 [
          "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>"
        ]
      ]
    ]
    "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>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres389802"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec368077"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres389801"
          "titulo" => "Resumo"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec368076"
          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case report 1"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Case report 2"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion and Conclusions"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-01-09"
    "fechaAceptado" => "2014-05-04"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec368077"
          "palabras" => array:4 [
            0 => "Pacemaker"
            1 => "Femoral vein"
            2 => "Technique"
            3 => "Complications"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec368076"
          "palabras" => array:4 [
            0 => "<span class="elsevierStyleItalic">Pacemaker</span>"
            1 => "Veia femoral"
            2 => "T&#233;cnica"
            3 => "Complica&#231;&#245;es"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "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>"
      ]
      "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>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "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>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2292
            "Ancho" => 2500
            "Tamanyo" => 406220
          ]
        ]
        "descripcion" => array:1 [
          "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>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2917
            "Ancho" => 2917
            "Tamanyo" => 577690
          ]
        ]
        "descripcion" => array:1 [
          "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>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2236
            "Ancho" => 2924
            "Tamanyo" => 482468
          ]
        ]
        "descripcion" => array:1 [
          "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>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 2694
            "Ancho" => 2924
            "Tamanyo" => 520090
          ]
        ]
        "descripcion" => array:1 [
          "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>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "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"
                            2 => "D&#46; Heaven"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/eupc.2000.0135"
                      "Revista" => array:6 [
                        "tituloSerie" => "Europace"
                        "fecha" => "2001"
                        "volumen" => "3"
                        "paginaInicial" => "56"
                        "paginaFinal" => "59"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11271953"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Permanent pacemaker implantation using the femoral vein&#58; a preliminary report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;H&#46; Ellestad"
                            1 => "R&#46; Caso"
                            2 => "P&#46;S&#46; Greenberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pacing Clin Electrophysiol"
                        "fecha" => "1980"
                        "volumen" => "3"
                        "paginaInicial" => "418"
                        "paginaFinal" => "423"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6160534"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Temporary transvenous pacing via the percutaneous femoral vein approach&#46; A prospective study of 100 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46; Weinstein"
                            1 => "J&#46; Gnoj"
                            2 => "J&#46;T&#46; Mazzara"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Heart J"
                        "fecha" => "1973"
                        "volumen" => "85"
                        "paginaInicial" => "695"
                        "paginaFinal" => "705"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4697639"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Iliac vein approach to permanent pacemaker implantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46;H&#46; Ellestad"
                            1 => "J&#46; French"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pacing Clin Electrophysiol"
                        "fecha" => "1989"
                        "volumen" => "12"
                        "paginaInicial" => "1030"
                        "paginaFinal" => "1033"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2476736"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Active-Can implantable cardioverter defibrillator placement from a femoral approach"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;C&#46; Giudici"
                            1 => "D&#46;L&#46; Paul"
                            2 => "C&#46;J&#46; Meierbachtol"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Pacing Clin Electrophysiol"
                        "fecha" => "2003"
                        "paginaInicial" => "261297"
                        "paginaFinal" => "261298"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Permanent transfemoral pacemaker implantation is the technique of choice for patients in whom the superior vena cava is inaccessible"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46; Barakat"
                            1 => "J&#46; Hill"
                            2 => "P&#46; Kelly"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pacing Clin Electrophysiol"
                        "fecha" => "2000"
                        "volumen" => "23"
                        "paginaInicial" => "446"
                        "paginaFinal" => "449"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10793432"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implantation of a biventricular implantable cardioverter defibrillator via the femoral vein"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "L&#46; Jourdier"
                            1 => "J&#46; Swinburn"
                            2 => "D&#46; Roberts"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1540-8159.2007.00711.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pacing Clin Electrophysiol"
                        "fecha" => "2007"
                        "volumen" => "30"
                        "paginaInicial" => "571"
                        "paginaFinal" => "572"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17437585"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac resynchronization via the femoral vein&#58; a novel method in cases with contraindications to the pectoral approach"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Z&#46; Yousef"
                            1 => "V&#46; Paul"
                            2 => "F&#46; Leyva"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/europace/euj025"
                      "Revista" => array:6 [
                        "tituloSerie" => "Europace"
                        "fecha" => "2006"
                        "volumen" => "8"
                        "paginaInicial" => "144"
                        "paginaFinal" => "146"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16627428"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Use of an active-fixation coronary sinus lead to implant a biventricular pacemaker via the femoral vein"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Shandling"
                            1 => "D&#46; Donohue"
                            2 => "S&#46; Tobias"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Tex Heart Inst J"
                        "fecha" => "2010"
                        "volumen" => "37"
                        "paginaInicial" => "92"
                        "paginaFinal" => "94"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20200636"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biventricular pacemaker implantation via the femoral vein"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Agosti"
                            1 => "C&#46; Brunelli"
                            2 => "G&#46; Berteroa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4021/jocmr920w"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Clin Med Res"
                        "fecha" => "2012"
                        "volumen" => "4"
                        "paginaInicial" => "289"
                        "paginaFinal" => "291"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22870178"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S016882270900432X"
                          "estado" => "S300"
                          "issn" => "01688227"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/21742049/0000003300000011/v1_201412120159/S2174204914002542/v1_201412120159/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "9919"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Case Reports"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003300000011/v1_201412120159/S2174204914002542/v1_201412120159/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002542?idApp=UINPBA00004E"
]
Share
Journal Information
Vol. 33. Issue 11.
Pages 733.e1-733.e6 (November 2014)
Visits
13642
Vol. 33. Issue 11.
Pages 733.e1-733.e6 (November 2014)
Case report
Open Access
Permanent pacemaker implantation using a femoral approach
Implantação de pacemaker definitivo por via femoral
Visits
13642
Patrícia Rodrigues
Corresponding author
pfdrodrigues@gmail.com

Corresponding author.
, Hipólito Reis, Vítor Lagarto, Paulo Palma, Carla Roque, António Pinheiro-Vieira, Diana Anjo, Severo Torres
Serviço de Cardiologia, Centro Hospitalar do Porto, Porto, Portugal
Related content
Rev Port Cardiol. 2015;34:367-810.1016/j.repce.2014.12.002
Gustavo Lima da Silva, Pedro Marques
This item has received

Under a Creative Commons license
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (4)
Show moreShow less
Abstract

We describe two cases in which a permanent pacemaker was implanted via the femoral vein, because the cephalic and subclavian veins were not patent.

The technique and its indications, advantages and potential complications are reviewed.

Keywords:
Pacemaker
Femoral vein
Technique
Complications
Resumo

Apresentamos dois casos em que foi implantado pacemaker definitivo por via femoral, pelo facto de não ser possível fazê-lo através da veia cefálica ou subclávia. Descrevemos a técnica, as suas indicações, as vantagens e as complicações associadas.

Palavras-chave:
Pacemaker
Veia femoral
Técnica
Complicações
Full Text
Introduction

Permanent pacemaker implantation via the femoral vein is an alternative for patients in whom access via the superior vena cava is impossible or contraindicated.1

We report two recent cases and review the technique and its indications, advantages and potential complications.

Case report 1

A.A., an 85-year-old woman, confined to bed or armchair and dependent for daily activities but with good personal relationships, had a history of type 2 diabetes (with diabetic nephropathy and under regular hemodialysis for nine years with a tunneled central venous catheter [CVC] for vascular access), chronic anemia of chronic disease, permanent atrial fibrillation, hypertension, Parkinson's disease and degenerative osteoarthritis.

The patient was medicated with insulin, carbidopa-levodopa, aspirin, darbepoetin alfa, calcium carbonate, B-complex vitamins, folic acid, omeprazole and metoclopramide.

She was admitted for sepsis arising from infection of the CVC in the right subclavian vein; intravenous antibiotic therapy with vancomycin and gentamicin was begun. Staphylococcus epidermidis was subsequently isolated in blood cultures.

Replacement of the CVC was attempted, but the catheter could not be moved and the patient became hemodynamically unstable; it was therefore decided to leave the CVC in place and to prolong antibiotic therapy, to which there was a good clinical response.

During hospitalization, periods of symptomatic atrial fibrillation with rapid ventricular rate were observed, alternating with periods of slow ventricular rate. A diagnosis of brady-tachycardia syndrome was therefore made, and the patient was referred for permanent pacemaker implantation.

Transthoracic echocardiography excluded significant structural heart disease.

Attempts were made to introduce the leads via the left cephalic and subclavian veins but they could not be advanced. It was also impossible to obtain vascular access via the right subclavian vein due to the presence of the CVC. Obstruction of the superior vena cava was documented by both fluoroscopy and computed tomography angiography (Figure 1).

Figure 1.

Top: Initial attempt at pacemaker implantation in the first patient, A.A., via puncture of the left subclavian vein, but the guidewire could not be advanced. The patient had a central venous catheter (CVC) in the right subclavian vein. Contrast administration showed obstruction of the superior vena cava (SVC). Bottom: computed tomography angiography images showing the CVC at the junction between the SVC and the right atrium, apparently adhering to a reduced-caliber SVC, which, combined with the collateral circulation observed, suggests secondary fibrosis of the SVC wall.

(0.39MB).

In view of the patient's limited mobility and the absence of alternative access sites, it was decided to implant a single-chamber permanent pacemaker in VVI mode via the femoral vein.

Following puncture of the right femoral vein, an 85-cm active-fixation ventricular lead was advanced up to the right ventricular apex. The lead was then tunneled subcutaneously to the right flank, where a pocket was fashioned to house and secure the pacemaker generator (Figure 2).

Figure 2.

Fluoroscopy images during placement of a single-chamber permanent pacemaker via the right femoral vein in patient A.A. A Relia SR pacemaker (Medtronic®) in VVI mode was implanted, with an 85-cm lead. (A) Site of lead insertion in the femoral vein and position of the generator in the right flank; (B and C) course of the lead up to the apex of the RV; (D) lead positioned in the RV. IVC: inferior vena cava; RV: right ventricle.

(0.55MB).

The procedure was uneventful, with good sensing and pacing parameters.

The patient was discharged with no further complications and is currently well. The pacemaker is functioning normally four months after implantation.

Case report 2

H.P., an 81-year-old woman, partially dependent due to limited right arm mobility and osteoarthritis, had a personal history of breast cancer diagnosed ten years previously and treated by right radical mastectomy, radiotherapy and chemotherapy, chronic lymphedema of the right arm, type 2 diabetes, hypertension, hypothyroidism and NYHA class II heart failure.

She was chronically medicated with oral antidiabetics, statins, amlodipine, valsartan, furosemide, spironolactone, levothyroxine, alprazolam and betahistine.

She was admitted for signs of decompensated heart failure and dizziness. On observation, she presented symptomatic bradycardia, with intermittent periods of Mobitz II and complete atrioventricular block. No electrolyte abnormalities or other reversible causes of bradyarrhythmia were identified.

Transthoracic echocardiography showed mild left ventricular systolic dysfunction (previously documented); analysis of wall motion were hindered by poor image quality, but no other relevant alterations were observed.

The patient was referred for permanent pacemaker implantation. Access via the left cephalic and subclavian veins was initially attempted but the leads could not be advanced (Figure 3). Despite marked lymphedema of the right arm, access via the right subclavian was also attempted but without success. Angiography confirmed obstruction at the level of the superior vena cava (Figure 3).

Figure 3.

Fluoroscopy images during attempts at pacemaker implantation in the second patient, H.P., via the left cephalic and right subclavian veins, without success. Contrast administration showed obstruction of the left (A and B) and right subclavian veins (C and D).

(0.46MB).

It was thus decided to implant a single-chamber permanent pacemaker via the right femoral vein, the lead being tunneled subcutaneously to the right flank and a generator pocket fashioned in the abdomen (Figure 4).

Figure 4.

Single-chamber Relia SR pacemaker (Medtronic®) implanted via the right femoral vein in patient H.P. Top: (A) lead placed in right ventricle; (B) generator positioned in right flank. Bottom: photographs taken during pacemaker implantation, showing incisions made in the femoral region for lead insertion and in the right flank for generator placement, the subcutaneous tunneling between them, and the final result. RV: right ventricle.

(0.5MB).

The procedure and remaining hospital stay were uneventful and the patient was discharged two days later. The pacemaker is functioning normally five months later, with good sensing and pacing thresholds.

Discussion and Conclusions

Permanent pacemaker implantation using the femoral vein was first described in the early 1980s,2 but it remains unfamiliar to most operators.

However, femoral access for transvenous temporary pacing is a frequent option, due to ease of implantation and low risk of periprocedural complications.3

The most common indications for transfemoral pacing are: abnormalities of the venous system, particularly obstruction of the subclavian vein or the superior vena cava; structural alterations of the anterior thoracic wall, for example following radiotherapy or mastectomy; pacemaker implantation in children; and the presence of multiple leads in the superior vena cava or recurrent infections of the generator pocket.

Femoral access is an effective alternative to the conventional approach. Other options include venous recanalization using laser energy or surgical placement of epicardial leads. However, laser-assisted recanalization would carry significant risk in the cases presented due to the length of the obstructed segments and the patients’ comorbidities and frailty.

The incision to introduce the leads via the femoral vein was made below the inguinal ligament in order to minimize discomfort from the scar. Others, such as Ellestad et al., have opted to use an iliac vein approach.4

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. Creation of a generator pocket in the upper thigh, an area with less subcutaneous tissue, is also likely to increase discomfort and the risk of erosion.5

Dislodgment of leads, particularly atrial leads, is a common complication of femoral or iliac vein approaches, occurring in around 20% of cases.1,4

Although not reported in the literature, a higher incidence of lead fracture might be expected with this approach, 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, allowing some slack in the subcutaneous course of the lead in order to prevent pulling when the leg is flexed. Furthermore, the groin is a less mobile region than the pectoral area, especially in elderly patients, and avoids crush injuries caused by the clavicle.

Rates of infection and deep vein thrombosis appear to be similar to the subclavian approach.6

Despite the lack of studies on the subject, most authors report a low rate of complications and the procedure, while more surgical in nature, is relatively easy to perform.1,4

In addition to pacemaker implantation, placement of cardioverter-defribillators5,7 and biventricular pacemakers8–10 using the femoral approach has also been reported.

Pacemaker implantation via the femoral vein should be considered when conventional access in the pectoral region is not possible.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
G. Mathur, R.H. Stables, D. Heaven, et al.
Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach.
Europace, 3 (2001), pp. 56-59
[2]
M.H. Ellestad, R. Caso, P.S. Greenberg.
Permanent pacemaker implantation using the femoral vein: a preliminary report.
Pacing Clin Electrophysiol, 3 (1980), pp. 418-423
[3]
J. Weinstein, J. Gnoj, J.T. Mazzara, et al.
Temporary transvenous pacing via the percutaneous femoral vein approach. A prospective study of 100 cases.
Am Heart J, 85 (1973), pp. 695-705
[4]
M.H. Ellestad, J. French.
Iliac vein approach to permanent pacemaker implantation.
Pacing Clin Electrophysiol, 12 (1989), pp. 1030-1033
[5]
M.C. Giudici, D.L. Paul, C.J. Meierbachtol.
Active-Can implantable cardioverter defibrillator placement from a femoral approach.
Pacing Clin Electrophysiol, (2003), pp. 261297-261298
[6]
K. Barakat, J. Hill, P. Kelly.
Permanent transfemoral pacemaker implantation is the technique of choice for patients in whom the superior vena cava is inaccessible.
Pacing Clin Electrophysiol, 23 (2000), pp. 446-449
[7]
L. Jourdier, J. Swinburn, D. Roberts, et al.
Implantation of a biventricular implantable cardioverter defibrillator via the femoral vein.
Pacing Clin Electrophysiol, 30 (2007), pp. 571-572
[8]
Z. Yousef, V. Paul, F. Leyva.
Cardiac resynchronization via the femoral vein: a novel method in cases with contraindications to the pectoral approach.
Europace, 8 (2006), pp. 144-146
[9]
A. Shandling, D. Donohue, S. Tobias, et al.
Use of an active-fixation coronary sinus lead to implant a biventricular pacemaker via the femoral vein.
Tex Heart Inst J, 37 (2010), pp. 92-94
[10]
S. Agosti, C. Brunelli, G. Berteroa.
Biventricular pacemaker implantation via the femoral vein.
J Clin Med Res, 4 (2012), pp. 289-291

Please cite this article as: Rodrigues P, Reis H, Lagarto V, et al. Implantação de pacemaker definitivo por via femoral. Rev Port Cardiol. 2014;33:733.

Copyright © 2014. Sociedade Portuguesa de Cardiologia
Download PDF
Idiomas
Revista Portuguesa de Cardiologia (English edition)
Article options
Tools
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

By checking that you are a health professional, you are stating that you are aware and accept that the Portuguese Journal of Cardiology (RPC) is the Data Controller that processes the personal information of users of its website, with its registered office at Campo Grande, n.º 28, 13.º, 1700-093 Lisbon, telephone 217 970 685 and 217 817 630, fax 217 931 095, and email revista@spc.pt. I declare for all purposes that the information provided herein is accurate and correct.