Occasionally, access may be difficult during a permanent pacemaker implant. Knowing the tricks of the trade are very important in order to perform an apparently complicated procedure quite easily.

Case Management. This patient is a 75-year-old woman with a history of lung carcinoma and a left lung lobectomy. She recently had atrial fibrillation with marked bradycardia as well as a syncopal episode resulting in a right occipital hematoma. The patient underwent attempted implantation of a permanent pacemaker elsewhere which was unsuccessful due to percutaneous access. The patient was subsequently transferred to Winthrop University Hospital for further management.

Informed consent was obtained from the patient. The patient was prepped and draped in the usual sterile manner. Prior to making an incision for the pacemaker pocket, a venogram was performed from the left brachial vein. This demonstrated a very tortuous subclavian vessel, which may be seen in Figure 1. Subsequently, we were able to access the vessel percutaneously using the Seldinger technique prior to making the pacemaker pocket. We were able to pass a Terumo Radifocus Glidewire (Figure 2), distributed by Boston Scientific Medi-Tech. This is a slippery wire with an angled tip, which is useful at crossing tortuous vasculature. We then subsequently placed a 5 French introducer sheath from the skin through the vessel and pulled out the Terumo wire. We then placed a standard J-wire into the blood vessel and removed the introducer sheath. We made an incision along the old incision line where prior attempt at pacemaker implantation was performed. We then tunneled the wire from the point of access underneath the subclavian down into the pocket. A standard Peel-Away introducer was placed and the wire was then removed.

A tined permanent pacemaker lead was positioned in the right ventricular apex and the lead was secured to the floor of the pacemaker pocket. The pocket was copiously irrigated with antibiotic solution and then the permanent pacemaker was secured. The pocket was then closed with 2-0 Dexon for a deep layer and a 4-0 Maxon for the subcuticular layer, and a bandage was placed over the wound.

Discussion. This patient had a failed attempt at pacemaker implantation, which was really not so difficult knowing the tricks of the trade. The Terumo guidewire can easily pass through the tortuous vessel. We have used this wire in very difficult access and occlusive situations both from the femoral vein/artery as well as from the upper chest vessels. Ultimate gratification comes from the successful result of implanting this device in this patient (Figure 3). Remember, the little tricks of the trade can be helpful in making a difficult case seem easy.