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Low incidence of complications after cephalic vein

cutdown for pacemaker lead implantation in children

weighing less than 10 kilograms: A single-center
experience with long-term follow-up
Bratislav Kircanski, MD,* Dragan Vasic, MD, PhD, Dragutin Savic, MD, PhD,*
Petar Stojanov, MD, PhD*
From the *Referral Pacemaker Center, Clinical Center of Serbia, Belgrade, Serbia, Vascular Surgery Clinic,
Clinical Center of Serbia, Belgrade, Serbia, and University of Belgrade, School of Medicine, Belgrade,
BACKGROUND Only a few studies on the cephalic vein cutdown
technique for pacemaker lead implantation in children weighing
r10 kg have been reported even though the procedure is widely
accepted in adults.
OBJECTIVE The purpose of this study was to prove that cephalic
vein cutdown for pacemaker lead implantation is a reliable technique
with a low incidence of complications in children weighing r10 kg.
METHODS The study included 44 children weighing r10 kg with
an endocardial pacemaker. Cephalic, subclavian, and axillary vein
diameters were measured by ultrasound before implantation. The
measured diameters were used to select either an endocardial or
epicardial surgical technique. Regular 6-month follow-up visits
included pacemaker interrogation and clinical and ultrasound
RESULTS Two dual-chamber and 42 single-chamber pacemakers
were implanted. Mean weight at implantation was 6.24 kg (range
2.2510.40 kg), and mean age was 11.4 months (range 1 day47

For years, endocardial pacing has been the technique of choice
for the adult population requiring a pacemaker. In the pediatric
pacing population, particularly in small children, there are
neither clear recommendations nor a consistent opinion
regarding the preferred implantation technique.1 Data from
adult pacing studies cannot be extrapolated to children
because permanent antibradycardia pacing in children is a
different entity than that in adults. This seemingly tendentious
assertion is supported by the essential differences in the
etiology of bradycardia, pacing indications, implantation
technique, and follow-up between children and adults.
The initial studies indicated that the epicardial approach is
better for children.2,3 This assertion was contested when
Address reprint requests and correspondence: Dr. Bratislav Kircanski,
Koste Todorovica 8, Clinical Center of Serbia, Belgrade 11000, Serbia.
E-mail address:

1547-5271/$-see front matter B 2015 Heart Rhythm Society. All rights reserved.

months). In 40 children (90.1%), the ventricular leads were

implanted using the cephalic vein cutdown technique, and implantation was accomplished via the prepared right external jugular
vein in 4 of the children (9.9%). The atrial leads were implanted
using axillary vein puncture and external jugular vein preparations.
Mean follow-up was 8.9 years (range 020.9 years). Only 1
pacemaker-related complication was detected (a lead fracture near
the connector that was successfully resolved using a lead
repair kit).
CONCLUSION The cephalic vein cutdown technique is feasible and
reliable in children weighing r10 kg, which justies the application of additional surgical effort in the treatment of these small
KEYWORDS Cephalic vein cutdown;
Complications; Long-term follow-up
(Heart Rhythm 2015;0:17)
rights reserved.



2015 Heart Rhythm Society. All

studies of the endocardial approach with positive results were

published.36 Endocardial pacing has become the preference
in the majority of centers. However, for children weighing
r10 kg, attitudes both for and against endocardial pacing
exist.5,7,8 More intriguing is the lack of evidence-based
opinions regarding endocardial lead implantation, that is,
whether subclavian vein puncture or cephalic vein cutdown
should be used in children weighing r10 kg. Therefore, the
goal of this study was to prove that permanent endocardial
pacing using cephalic vein cutdown for lead implantation is a
reliable and safe method with a low incidence of complications over long-term follow-up for children weighing r10 kg.

Study population
From May 1989 to December 2012, permanent antibradycardia pacemakers were implanted in 46 children weighing

Heart Rhythm, Vol 0, No 0, Month 2015

r10 kg at 3 centers: (1) the University Children's Hospital,

Belgrade; (2) the Institute for Mother and Child Health Care
of Serbia, Belgrade; and (3) the Referral Pacemaker Center,
Clinical Center of Serbia, Belgrade. This retrospective study
included 44 children with endocardial pacemakers. In 2
children, the epicardial system was used because of the small
diameter of the subclavian veins (o2.2 mm); hence, these
children were not subjected to further follow-up.
The study protocol was approved by the Ethics Committee of the Clinical Center of Serbia and complied with the
Declaration of Helsinki. Written consent was obtained from
all patients (provided by their parents, in accordance with
local law).

Implantation technique
All implantations were performed by a single surgeon (P.
Stojanov from the Referral Pacemaker Center) under general
endotracheal anesthesia in the operating room or catheterization laboratory. In the majority of cases, surgical loupe
magnifying glasses with 3 magnication were used during
the operations. Single- and dual-chamber pacemakers were
implanted in both sides but were predominately implanted in
the right side.
Since 2001, collection of preoperative ultrasonographic
measurements of the cephalic, subclavian, and axillary vein
diameters has been mandatory in our practice for children
younger than 3 years (we later applied this regulation to
children weighing r10 kg). These measurements allow for
selection of the optimal approach vein (ie, cephalic, external
jugular, or axillary vein), optimal pacing lead (based on the
consideration that the lead diameter should not exceed 50%
of the axillary or subclavian vein diameter), and, most
importantly, the appropriate surgical technique (ie, epicardial
or endocardial). The epicardial approach was used when the
diameter of the axillary or subclavian vein was o2.2 mm.
Our surgical technique proceeded as follows. A 3- to 4-cm
incision was made 12 cm infraclavicularly starting from
deltopectoral groove and extending medially and in parallel
to the clavicle. Next, a subcutaneous prepectoral pocket for

Figure 1 Cephalic vein diameter enlargement near the conuence of the

axillary vein makes it suitable for lead insertion.

Figure 2 Directly xing the lead with resorptive sutures (without the use
of a sleeve).

the pulse generator was created via a sharp surgical

preparation and placed beneath the major pectoral muscle
fascia as medially as possible to reduce the risks of pocket
decubitus and fracture of the extravascular portion of the lead
due to generator movement during shoulder and arm motion.
After identifying the cephalic vein in the deltopectoral
groove, we assessed whether it was possible to introduce
a unipolar lead. If the vein diameter was appropriate (Z2
mm), a venotomy was created transversely with sharp
scissors or a blade. The venotomy did not exceed one third
of the veins diameter to avoid the risk of vein rupture during
lead insertion. After successful venotomy, we dilated the
vein with a ne surgical pean or tweezers to facilitate lead
insertion. Venous lifters for endocardial leads that are
provided by the manufacturers are not useful in this situation
because they are too large for small veins (r2 mm). Instead,
we used ne microvascular tweezers for lead insertion.
Typically, it was necessary to prepare the cephalic vein up
to its conuence with the axillary vein for children weighing
r5 kg (and less often in other children) because its diameter
in the deltopectoral groove was inappropriate for unipolar
lead insertion. To enable this preparation, we were forced to
partially detach the major pectoral muscle from the clavicle
for approximately 11.5 cm (this procedure was performed
in 18 children, and the detachments were reconstructed
before wound closure). Negative consequences of this
procedure on ipsilateral arm motion were not observed
during follow-up. The cephalic vein most often receives
tributaries close to the axillary vein conuence, which causes
a 1- to 1.5-mm diameter enlargement before the conuence,
which makes it suitable for lead insertion (Figure 1). In rare
cases, the cephalic vein was too small for lead insertion even
at this point; in such cases, the cephalic vein was cut off just
before the conuence and the cut was spread toward the
axillary vein (Figure 2). Bleeding control was achieved with
double-loop sutures (5-0) that were applied proximally and
distally on the axillary vein. The venotomy was closed with a
nonabsorbable suture (6-0 or 7-0).
We directly xed the lead with resorptive sutures (4-0 or
5-0) while exercising care not to apply inappropriate force

Kircanski et al

Cephalic Vein Cutdown for Pacemaker Lead Implantation in Children

that might damage the insulation. This process prevents

acute lead dislodgment and, after ligature resorption and lead
tip in-growth, enables the slip and extraction of the lead
due to growth. Because of the small diameters of the veins, it
was impossible to use lead sleeves. A redundant loop of the
lead was also left in the right atrium to account for initial
In 4 patients, the external jugular vein was used for lead
insertion. Because this is a subcutaneous vein, the surgical
technique was simple. The technique included an incision in
the skin over the vein, vein preparation, lead insertion and
tunneling of the lead beneath the platysma muscle and over
the clavicle to the pocket.
A Medtronic pacing system analyzer (model 5311,
Medtronic Inc, Minneapolis, MN) was used to measure the
pacing thresholds and impedance and to register R- and Pwave amplitudes during implantation. During implantation,
we required high R-wave amplitudes (412 mV) and low
acute stimulation thresholds (o1 V/0.5 ms).
Antibiotics were intravenously administered in prophylactic dosages 30 minutes before the interventions and were
continued for the next 5 days.

Follow-up visits were 1 month after the implantation and every
6 months thereafter. All follow-up visits were performed by the
implanting surgeon and included pacemaker interrogation and
clinical examination to identify supercial cutaneous collateral
vein engorgement (ipsilateral to the implanted pacemaker),
which is sign of subclavian vein thrombosis.
Ultrasound examinations of the axillary and subclavian
veins were performed by a sonographer/angiologist from the
national referral clinic for vascular surgery. All of the
measurements were performed according to standard protocols, with the patient in the supine position and the patients
head turned slightly to the contralateral side. Images were
acquired from the longitudinal views of the far walls of veins
and analyzed from the proximal to distal ends to estimate the
ultrasonographic ndings of acute or chronic vein thrombosis. All studies were performed using a Siemens Acuson
Antares Ultrasound System (Siemens AG, Erlangen, Germany) using a linear array and 7- and 14-MHz scan heads.
Chest radiographs were obtained to monitor lead lengths
during growth once per year at the beginning of the study.
After we had gained experience, these radiographs were
obtained every second or third year.

Failure-free systems
A failure-free system was dened as a pacemaker system that
met the following criteria for the entire duration of followup: (1) no need for any type of surgical reintervention; (2)
stimulation threshold did not increase above 3 V at a pulse
width of 1.0 ms, and the amplitudes of the R and P waves
remained over 5 mV and 0.5 mV, respectively; and (3) no
signicant stenosis/obstruction in the venous system used for
lead insertion.

Statistical analysis
The descriptive statistics used for data presentation included
measures of the central tendency (mean), measures of
variability (range). and relative numbers. The statistical tools
of Microsoft Ofce Excel for Mac 1 (version 14.3) were used
for statistical analyses.

The endocardial systems of 44 children, including 24
(54.5%) boys and 20 (45.5%) girls, were successfully
implanted. At implantation, mean weight, height, and age
were 6.24 kg (range 2.2510.40 kg), 66.7 cm (range 4886
cm), and 11.4 months (1 day47 months), respectively. All
implantations were performed within a period of 23.5 years.
The indications for pacing were isolated congenital complete
atrioventricular block in 23 children (52.2%) and postsurgical complete atrioventricular block in 21 children (47.8%;
latter occurred primarily after ventricular septal defect
Single-chamber pacemakers were implanted in 42 children (95.5%) and dual-chamber pacemakers in 2 children
(4.5%; in both cases, the implantation was performed
because of complete atrioventricular block after surgical
correction of tetralogy of Fallot defects). All of the ventricular leads were standard length, passive xation, and
steroid eluting. Forty-three of the leads (97.8%) were
unipolar, and 1 (2.2%) was bipolar. Both of the atrial leads
of the dual-chamber systems were active and standard
length; 1 was bipolar, and the other 1 was unipolar. The
unipolar leads had lead body diameters of 1.2 mm (3.6Fr)
and 1.7 mm (5.1Fr). The bipolar lead body diameter was 2.2
mm (6.6Fr). In 40 children (90.1%), the ventricular leads
were implanted using the cephalic vein cutdown technique.
In 4 of the children (9.9%), the ventricular leads were
implanted after right external jugular vein preparation. The
reasons for the selection of the external jugular vein were
sharp angulation of the conuence of the internal jugular
vein and the subclavian vein that guided the lead cranially in
the rst child; partial thrombosis of the cephalic vein in the
second child; and small diameters of the cephalic veins in
the last 2 children (1.2 and 1.4 mm at the conuence with the
subclavian vein). In the children with a dual-chamber pacemaker, the accessing veins that were for the atrial leads were
the right axillary vein (puncture technique) in 1 child and the
right external jugular vein in the other. In 30 children
(68.1%), the diameters of the cephalic, axillary, and subclavian veins, as measured in millimeters by ultrasound
before implantation, were 1.98 (range 13.5), 3.43 (range 2
6.6), and 3.56 (range 2.27.5), respectively.
Postoperative clinical examinations were performed in 40
children (90.1%) to identify signs of subclavian vein
thrombosis. No supercial cutaneous collateral vein
engorgement ipsilateral to the implanted pacemaker was
observed in any of these children. Postoperative ultrasound
examinations of the axillary and subclavian veins were
performed in all of these children. In 5 of these patients

Heart Rhythm, Vol 0, No 0, Month 2015

Figure 3

Thickening of the subclavian vein wall at the level of the implanted lead (arrow). SA subclavian artery.

(12.5%), these examinations revealed mild stenoses in the

form of thin thrombi or brotic changes around the leads.
Stenoses were narrowing the lumen up to 30% and were
classied as nonsignicant (Figure 3). The venous ow was
spontaneous and phasic (Table 1).
One patient died of sepsis after a respiratory infection 19
days after implantation. The function of the implanted
pacemaker was normal. Three patients were lost to followup. The rst was lost to follow-up after 192 months because
of implantation of a prosthetic heart valve and intraoperative
conversion to epicardial cardiac resynchronization therapy.
Two patients were lost to follow-up because they moved to
another state, after 38 months of follow-up in 1 case and
immediately after implantation in the other case. The patient
who died 19 days after implantation and the patient who was
lost immediately after implantation were not included in the
nal analyses. Mean follow-up for the remaining 42 patients
was 8.9 pacing years (range 0.520.9 pacing years). Total
follow-up was 356.5 pacing years. Nine patients reached
legal age (18 years) during follow-up.
The pulse generators were replaced in 18 patients because
of battery depletion. Eight patients underwent 1 replacement,
Table 1

8 patients underwent 2 replacements, and 2 patients underwent 3 replacements. The initial implantation was performed in the period from 2005 to 2012 in 24 patients.
In 6 patients (age 715 years), the system was upgraded to
dual-chamber at the time of elective battery replacement.
All atrial leads were easily placed after axillary vein
puncturing without complications or the need for phlebography. Moreover, there was no need for lead length adjustment because of the absorbable sutures that were used in the
initial xations.
The average stimulation threshold for the ventricular lead
was 1.37 0.34 V, the average R wave was 9.71 3.05
mV, and average ventricular lead impedance was 471 46
. Average battery longevity was 6.8 1.9 years.
During the entire follow-up period, no complications
(pocket hematomas or decubitus, pacemaker infection, lead
dislodgment, or exit block) were noted, except for 1 lead
fracture near the connector, which was detected 37 months
after implantation. This complication was successfully
resolved using a lead repair kit.
In 41 of the total of 42 children (97.6%), the system
remained failure-free during the follow-up period.

Patients with ultrasonographically detected stenoses of the axillary or subclavian vein


Age at implantation

Weight at
implantation (kg)

Implanted lead

Lead body
diameter (mm)

Follow-up period to
detected stenosis

degree (%)









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Cephalic Vein Cutdown for Pacemaker Lead Implantation in Children

Only 1% of patients who underwent pacemaker implantation
are younger than 20 years.9 The subgroup of the pediatric
pacing population weighing r10 kg is even smaller. A
review of the literature revealed that permanent endocardial
pacing in patients weighing r10 kg has been applied to 82
patients (in publications that explicitly mention patients
body weights and implantation techniques).1014 Our series
of 44 patients weighing r10 kg who underwent endocardial
lead implantation with the cephalic (or external jugular) vein
cutdown technique currently represents the largest single
series. This series is distinguished by the low number of
complications (ie, system failure rate of 2.7%) over the long
follow-up period (mean 8.9 years). This series includes our
overall experience with the cephalic vein cutdown technique,
which we have been implementing in even the smallest
children for more than 23 years.15,16
The dilemma regarding use of the epicardial vs the
endocardial approach for pacing in children is old7 but
remains current and challenging,8 especially with regard to
young children. To the best of our knowledge, no randomized
study comparing the epicardial and endocardial approaches
has yet been published. Similarly, no single randomized or
nonrandomized pediatric study has been published regarding a
less frequently mentioned but no less important topicthe
comparison of implantation techniques for endocardial pacing
(eg, subclavian vein puncture vs cephalic vein cutdown).
In 1 study, reoperations were not needed in 80% of
children who had undergone epicardial pacing after 6 years
of follow-up.17 However, much worse results have been
reported (eg, 44% of patients requiring reintervention with
median follow-up of 6.4 years18 and epicardial lead dysfunction in 40.5% of patients after 3.5 3 years of followup12). The unfavorable aspects of the epicardial approach are
as follows: (1) this intervention is more invasive (ie, it
includes sternotomy or thoracotomy); (2) epicardial lead
fractures are more frequent than endocardial lead fractures
(because of greater mechanical stress)2; and (3) there are
higher stimulation thresholds4,12 and decreased battery
longevities compared with endocardial systems. The benets
of the epicardial approach when vein anomalies, thromboses,
or occlusions are present cannot be denied. Epicardial pacing
might also be preferable in children with certain congenital
heart defects19 or when right-to-left shunts are present
(because of risk of systemic embolization). As a rst argument in favor of epicardial access, many investigators have
highlighted the fact that venous access is preserved for
possible later endocardial implantation. They argued that,
with the epicardial approach, the risks of venous thrombosis
and occlusion are avoided.19,20 In our opinion, despite the
downsides of epicardial pacing, this technique is nearly
always feasible and might be used as a backup technique.
The predominance of the endocardial over the epicardial
approach in pediatric pacing has been recognized for years,20
but the endocardial approach became widespread in the
youngest pacing population after several cases of successful
endocardial implantations in newborns were reported.15

Endocardial implantation is associated with less surgical

trauma and better pacing characteristics compared with
epicardial implantation.4,12
The main disadvantages of the endocardial approach are
the risks of subclavian vein thrombosis,5,21 lead dislodgment
due to growth,22 and inadequacy of endocardial lead
implantation for some heart defects (eg, single ventricular
physiology post-Fontan palliation).
In the rst decades of cardiac pacing, implantations were the
exclusive jurisdiction of surgeons. Insertion of an endocardial
lead was performed through a surgically prepared vein (eg,
cephalic, external jugular, or internal jugular vein). After the
introduction of the subclavian vein puncture technique into
clinical practice (ie, modied Seldinger technique), an
increased number of cardiologists began to perform pacemaker
implantations. Currently, it is estimated that the majority of
endocardial pacemaker implantations are performed by cardiologists. Subclavian vein puncture became the dominant
method of endocardial lead insertion in both adults and
children.23 In our opinion, a clear distinction between the vein
approach techniques for endocardial pacing should be made
between the subclavian vein puncture and the preparation (of
the cephalic or external jugular vein) techniques. This issue has
not yet been studied in the pacing population weighing r10
kg. Moreover, subclavian vein puncture has been used in nearly
all series of these patients.12,14,24,25 In 1 study, the cephalic vein
was identied in nearly all patients, but subclavian vein
punctures were performed nonetheless.10 Additional proof that
the importance of this problem is not properly recognized is the
fact that, in some studies, the implantation technique (ie,
puncture or preparation) was not even specied.8,26
Because vein puncture is a blind technique that is
guided by certain anatomic markers, it is possible to injure
the surrounding anatomic structures. Complications (eg,
pneumothorax, hematothorax, pneumohemothorax, brachial
plexus lesions) can occur. These complications can be
avoided via the use of cephalic vein preparation. Insertion
of the lead using the puncture technique typically requires a
7Fr (2.4-mm) or larger venous introducer sheath. The
average diameters of the axillary and subclavian veins as
measured preoperatively with ultrasound in the 30 patients in
our study were 3.43 mm (range 26.6 mm) and 3.56 mm
(range 2.27.5 mm), respectively. The diameter of a 7Fr (2.4mm) venous introducer sheath thus comprises 69.5% of
the average diameter of the axillary vein and 67.4% of the
average diameter of the subclavian vein. Of note, the
introducer sheath diameter can be greater than the diameter of
the axillary or subclavian vein in some patients. As recognized by Virchow27 in 1856, venous puncture and the use of
introducer sheaths lead to vessel wall injury and a prothrombotic state. However, venous wall injury can be avoided via
use of cephalic or external jugular vein preparation techniques. The incidence of venous thrombosis after endocardial
pacing in pediatric populations varies from 0% and
21%.5,21,28 Only 5 patients (12.5%) in our study exhibited
organized brous sheaths around the leads, which led to up
to 30% narrowing of the lumen. Fibrous organized thrombi

Heart Rhythm, Vol 0, No 0, Month 2015

Figure 4

Chest radiographies taken immediately after implantation (A) and after 20 years (B).

around the leads are normal pathoanatomic ndings.29 The

absence of signicant venous complications in our study
might also be explained by the implantation of unipolar leads
(93% of all leads). Unipolar lead diameters are small (1.2
mm), which aids in the initial avoidance of signicant
narrowing of the venous lumen.
An equally important advantage of the preparation technique
is the avoidance of lead damage due to costoclavicular scissors.
Leads that are placed via cephalic vein cutdown use a natural
route through the venous system to the large veins of the thorax.
This route avoids complications such as damage to the lead
insulation or the conductor or lead breaks that could occur in
patients with leads that were implanted via subclavian vein
puncture. These complications are generated by shoulder movements and lead jamming by the costoclavicular ligament (through
which the lead passes on its path from the pacemaker pocket to
the subclavian vein). To a lesser extent, the lead also could be
damaged by subclavian muscle contractions. These facts have
been experimentally validated in a study performed on cadavers
by Jacobs et al.30 Based on autopsy ndings, an excellent analysis
of the mechanisms of lead damage after subclavian vein puncture
performed by Magney et al31 produced similar results. Despite the
negative results of these studies, subclavian vein puncture remains
the dominant method of endocardial lead implantation, primarily
because cephalic vein cutdown requires greater surgical skills
compared with subclavian vein puncture.
In our study, 1 lead fracture close to the connector was
noted. Signicantly higher numbers of lead complications
have been observed with epicardial leads32 and leads that
were implanted via subclavian vein puncture6,12 in studies of
children weighing r10 kg. A low rate of lead survival (78%
after 3 years) after cephalic vein cutdown was reported by
Spotnitz et al33 in a series of 17 children younger than 6
months. The technique of those investigators was most

similar to ours, but they used a larger-diameter lead (7Fr)

and presented no data on lead xation in that series.
The lead fracture that occurred in our study was not related
to the implantation technique per se. This complication was
successfully resolved using a lead repair kit. Theoretically,
because only 7% of lead fractures occur intravascularly, 93% of
broken leads can be repaired provided they are unipolar.34 The
possibility of repair (which delays new lead implantation), the
smaller lead diameter, and the authors positive experience of
the durability of repaired unipolar leads justify their use.
Another potential problem of endocardial pacing in children is lead dislodgment due to growth. We solved this
problem by leaving the right atrial loop13 and xing the lead
for the vein with resorptive sutures to prevent early dislodgment. After ingrowth of the lead in the endocardium and
resorption of the ligature, the lead was able to slide and extract
as the child grew (Figure 4); thus, no reinterventions for lead
adjustment were required because of growth in our study.

Study limitations
A limitation of this study was that it was a single-center
retrospective study without a puncture technique control group.

This long-term follow-up study revealed that cephalic vein
cutdown for endocardial lead implantation in children
weighing r10 kg is a successful technique. Based on
personal experience with both epicardial and endocardial
pacing in children weighing r10 kg, our opinion is that the
endocardial approach is more demanding from the surgical
perspective because of the delicate anatomic structures. Our
personal negative experiences, which have been conrmed
in other studies30,31 with the puncture technique, motivated

Kircanski et al

Cephalic Vein Cutdown for Pacemaker Lead Implantation in Children

our preference for the cephalic vein cutdown technique. The

good clinical results of our study seem to justify the
additional surgical effort.
We believe that the numbers of years of experience with
the preferred implantation technique will remain the primary
factor that motivates implanters/centers to continue using the
same surgical technique. The choice of technique for lead
implantation for pacing in children will remain an area of
eminence-based medicine until the results of large randomized prospective clinical trials become available.

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This is the largest single series of patients weighing less 10 kg who have undergone endocardial pacemaker lead
implantation using the cephalic vein cutdown technique. The low incidence of complications observed during long-term
follow-up conrm that this technique, which is widely accepted and considered to be the technique of choice for adults, is
also feasible for this specic group of patients. Complications related to subclavian vein puncture (eg, pneumothorax,
hematothorax, brachial plexus lesions, arterial lesions) can be avoided, as can the signicant trauma related to the
thoracotomy required by the epicardial approach. Teams that include an experienced vascular surgeon, an angiologist, and a
pacemaker expert could implement this technique and improve the prognosis of this group of small patents who typically
require pacemaker therapy for their entire lifetimes.