**6.3 Central venous access**

Tran's venous lead implantation is commonly performed through venous access via the right or left cephalic, subclavian or axillary vein. In case clinical signs of a venous occlusion of deep veins of the upper extremity are observed, preoperative assessment (colored Doppler sonogram, venography, or chest CT scan) may be useful to determine optimal venous access or find an alternative access way.

**Figure 3.** *Right infraclavicular incision region and marker.*

**Figure 4.** *Right pectoralis major fascia.*

By applying the Seldinger technique, we first enter the right subclavian vein using a needle and syringe. Then, we insert a guide wire through the subclavian vein, superior vena cava, and the right atrium, determining the proper location using fluoroscopy. The lead introducer (7 French or 9 French) is sent through a guide wire and then the right ventricular (RV) lead (58 cm length) is passed through the introducer to the RV apex or interventricular septum, latter for patients who need more RV and LV contractile synchronization (**Figure 5**). The second guide wire is passed through the subclavian vein to the right atrium, and the 52 cm length lead is placed inside the right atrial appendage in the same manner and analyzed by a pacemaker programmer. An alternative technique is cephalic vein cut-down, which is occasionally performed by surgeons to reduce side effects. Subclavian vein access is associated with a 7.8-fold increased risk of pneumothorax [1]. In case subclavian venous access is not feasible, transfemoral lead implantation is alternatively performed, or leadless PPM or epicardial lead should be considered.

*Pacemakers and Defibrillators Implantation DOI: http://dx.doi.org/10.5772/intechopen.101518*

#### **Figure 5.**

*Proper position of activated leads in right atrial appendage and right ventricular apex with noticeable tip position.*
