This report describes two cases in which upper extremity vascular occlusion precluded sub-pectoral implantation, at which time the patient opted for the femoral approach. Previous literature describes successful follow-up periods of up to six months.1–3 This report documents long-term success of 21 months. Case Report #1 The patient is a 69-year-old woman with a history of hypertension, coronary artery disease with stent placement, and chronic renal failure receiving scheduled hemodialysis through a PermCath® placed in the right subclavian vein. She uses home oxygen therapy and has had several infections and a history of endocarditis as a result of the dialysis catheter. Her LVEF by echocardiogram was 20-25%. The patient presented to the emergency room of a large tertiary hospital in March of 2005 with complaints of left-sided chest pain and shortness of breath, and was admitted for further evaluation. The Electrophysiology Department was consulted after runs of non-sustained ventricular tachycardia were observed on telemetry. Based on her cardiovascular history, an EP study was performed; rapid ventricular tachycardia was induced with triple extrastimuli using a drive train of 400 milliseconds. Hemodynamic collapse ensued, and DC cardioversion was required to restore normal sinus rhythm. ICD implantation was attempted unsuccessfully using the left subclavian venous site due to severe stenosis (Figure 1), and the right side was unavailable due to the dialysis shunt. After discussing with the patient and weighing the risks and benefits of both the epicardial and femoral vein approaches, the femoral vein approach was attempted. The right groin and abdominal area were prepared in standard sterile fashion. Access was obtained to the right common femoral vein using the modified Seldinger technique, and Boston Scientific’s Glidewire® was inserted up to the level of the right atrium. Progressive dilatation of the vein was performed with 7–11 French dilators, and a 9 French introducer was placed into the femoral vein. A dual coil active fixation lead (model 6949, Medtronic, Minneapolis, Minnesota) was advanced to the right ventricle and placed in the mid-septum after unsuccessful attempts at apical placement. The helix of the active fixation lead was deployed and subsequent lead analysis was within normal limits [R waves were 19 mv, threshold of 0.5v @ 0.5 msec; impedance of 734Ω and 46Ω]. A subcutaneous pocket was made in the upper left abdominal quadrant and the lead was tunneled upward and connected to Medtronic’s 7232 Maximo VR ICD. Defibrillation threshold testing was attempted unsuccessfully at both 25 and 35 joules. Shock vector polarity was reversed, and defibrillation testing was again unsuccessful at 25 and 35 joules. A single element subcutaneous array electrode (Medtronic model 6996 SQ) was implanted along the left chest border and connected to the ICD. Ventricular fibrillation was induced again, and the device was successful at terminating ventricular fibrillation twice at 25 joules. The device was set to detect ventricular tachyarrhythmias faster than 188 beats per minute and deliver 35 joules up to six times. Bradycardia pacing was set at 40 beats per minute to avoid unnecessary ventricular pacing. Chest radiographs confirmed the position of device (Figure 2). The patient was subsequently discharged from the hospital in good condition. Routine device follow-up has been maintained over a 21-month follow-up period. The patient has received no defibrillation therapy since the initial implant; however, multiple episodes of non-sustained ventricular tachycardia have been detected by the device and therapy withheld appropriately. Intrinsic R wave, pacing lead impedance and pacing threshold has remained stable with no evidence of over- or undersensing occurring during the routine monitoring of the device. The patient remains active. Case Report #2 We report a case of 58-year-old woman with a history of dilated cardiomyopathy, coronary artery disease, mitral regurgitation status post mitral valve repair, end-stage renal disease on hemodialysis, and severe peripheral vascular disease. Her ejection fraction was 20%. She presented to another hospital with an episode of syncope, and while being monitored on telemetry she had episodes of sustained ventricular tachycardia. She was externally defibrillated, and an attempt was made to place an ICD through the left subclavian approach. Unfortunately, this attempt was unsuccessful because of the presence of obstruction in the distal portion; the patient has an AV graft in the right upper extremity, and implantation through the right subclavian vein would have impaired the patency of the graft. The patient was electively transferred for possible epicardial lead placement or for placement of the ICD via the femoral approach. Venography of the left upper extremity showed complete occlusion of the subclavian vein (Figure 3). An initial attempt was made to place the lead through the left subclavian, which was unsuccessful due to obstruction of left innominate. Prior to the procedure, a discussion was held with the patient about placement of the ICD via the left femoral approach and tunneling the lead in the left upper quadrant of the abdomen. The patient preferred this approach as opposed to placement of an epicardial ICD system, which would have required thoracotomy. The left groin and abdominal area were prepared in standard sterile fashion. The vascular access was obtained through the left common femoral vein, and a dual coil active fixation ICD lead (model 6949, 100 cm; Medtronic) was advanced and placed in the right ventricular apex under fluoroscopic guidance. The analysis revealed that R waves were 19.0 mv; impedance 651Ω; shock lead impedance 35Ω; threshold 1.5v @ 0.5 msec. The lead was tunneled via the anterior abdominal wall to the left upper quadrant of the abdomen, and attached to an ICD generator (model T180, Guidant Corporation); defibrillation threshold was tested and was noted to be 31 joules. Subsequent abdominal (Figure 4) and chest x-rays (Figure 5) showed that the device was in the appropriate location. The patient's postoperative course was not remarkable. Subsequently she was discharged in a stable condition. She has a routine device follow-up for 18 months. Intrinsic R wave, pacing lead impedance and pacing threshold has remained stable with no evidence of over- or undersensing occurring during the routine monitoring of the device. The device remained in position as noted in a recent radiograph (Figure 6) and did not require any repositioning. Discussion We report two cases of successful ICD placement by femoral approach in patients who have upper extremity vascular occlusion. In both cases the device was successfully implanted without the need for repositioning, and a mean follow-up of 19.5 months showed that the device was properly functioning. Since a large number of patients who meet the criteria for ICD placement have multiple other comorbidities such as peripheral vascular disease, or end-stage renal disease on hemodialysis (AV grafts in upper extremities), where the vascular access via the traditional routes is limited, femoral approach could be a safe alternative in these patients.