Axillary subpectoral approach for pacemaker or defibrillator implantation in patients with ipsilateral prepectoral infection and limited venous access

Purpose The prepectoral approach is the procedure of choice for pacemaker or defibrillator (device) implantation. Epicardial or transiliac approaches are reserved for patients in whom the pectoral approach is not feasible. We studied the viability of the axillary subpectoral approach for implanting devices in patients in whom the standard prepectoral approach was not feasible. Methods Devices and leads were extracted from 16 patients with infected devices in the prepectoral position. The contralateral site was unsuitable for reimplantation because of infection or inadequate venous access. On the side ipsilateral to that with prior prepectoral device infection, we made an incision on the anterior axillary line along the border of the pectoralis major; dissection was continued below the muscle to create a pocket for generator implantation. Axillary venous puncture was performed from the axillary incision and beneath the pectoralis major muscle using a long 14-gauge needle. Long guidewires and peel-away sheaths were used for positioning the lead. The generator was placed in the subpectoral pocket; the wound was closed with absorbable sutures. Results One patient developed a pocket hematoma; one developed a pneumothorax; no other surgical complication, lead malfunction, or recurrence of infection was observed. Conclusion The axillary subpectoral approach is an acceptable, technically feasible method for reimplantation for patients with pectoral device infection and limited venous access options. It offers the advantage of a new sterile fascial plane ipsilateral to the site of prepectoral device infection.