Pacemaker Implantation
Through the Internal JugularVein
Richard Brodman, M.D., and Seymour Furman, M.D.
ABSTRACT During a twelve-year experience with
1,808 patients, 90 underwent permanent transvenous
implantation through the ligated internal jugular
vein. Ninety-two implants were performed. In 2 of
the patients both internal jugular veins were used
without complication. Out of the ninety-two im-
plants there were three complications; one perma-
nent recurrent laryngeal nerve injury and two epi-
sodes of severe thrombophlebitis, which receded
with nonoperativetherapy. The internal jugular vein
is a useful and safe route for permanent pacemaker
implant.
Placement of a permanent transvenous pacing
electrode can be performed through a number
of veins. The most acceptable are those easily
accessible to the surgeon and as near as possi-
ble to the right heart. In order of preference, we
use the cephalic vein, the external jugular vein,
and the internal jugular vein on the same side.
Of the 1,808 transvenous pacemaker implants
performed during the past twelve years at
Montefiore Hospital and Medical Center and
available for study, 92 implants, or 5%, were
performed in 90 patients using the internal
jugular vein. The internal jugular vein has been
found to have an acceptably low complication
rate.
Methods
The method for implantation of a permanent
pacemaker is as follows: With local anesthesia,
an incision 5 to 8 cm long is made over the
deltopectoral groove. The cephalic vein is iso-
lated, and a medially directed subcutaneous
pocket for the pulse generator is created. The
cephalic vein was unusable in 23% (433 of
From the Department of Surgery, Cardiothoracic Division,
Montefiore Hospital and Medical Center, Bronx, NY.
Supported in part by United States Public Health Service
Grant No. HE-04666-20.
Accepted for publication Mar 28, 1979.
Address reprint requests to Dr. Furman, 111 E 210th St,
Bronx, NY 10467.
63 0003-49751801010063-03$01.25@ 1978 by Richard Brodman
1,808) of the implants. In these instances, the
external jugular vein was sought and used suc-
cessfully in 341 (19'%0). To expose the external
jugular vein, an incision is made just above the
clavicle between the posterior border of the
sternocleidomastoid muscle and anterior bor-
der of the trapezius muscle where the external
jugular vein is isolated (Fig 1). The external
jugular vein was not usable in 21% (92 of 433) of
the procedures in which it was sought. The in-
cidence of an unusable external jugular vein is
similar to that of an unusable cephalic vein.
Ninety patients remained in whom the inter-
nal jugular vein was used 92 times (5%). In 59
of these 92 implants, the cephalic vein was too
small or not present; in 23, it had been used
previously and could not be reused and in 10, it
did not communicate with the superior vena
cava (Table). The external jugular vein was too
small or not present in 71 instances, was not
reusable in 11, and did not provide a satisfac-
tory path to the superior vena cava in 10.
To expose the internal jugular vein, the inci-
sion over the clavicle, used to expose the exter-
nal jugular vein, is extended anterior to the
sternal head of the sternocleidomastoid muscle.
The carotid sheath is exposed by opening the
superficial investing fascia behind the posterior
border of the sternocleidomastoid muscle, el-
evating the muscle and staying anterior to the
omohyoid muscle and its fascia (Fig 2). Should
further exposure be needed, the clavicular head
of the sternocleidomastoid can be divided and
the carotid sheath exposed deep to it (see Fig 2).
If the sternocleidomastoid muscle is divided, it
is reapproximated at the conclusion of the pro-
cedure. The carotid sheath is opened, and the
internal jugular vein is dissected circumferen-
tially for about 2.5 cm; two ties of synthetic
nonabsorbable suture are placed around it. The
more cephalad suture is tied, and the other is
looped again around the vessel to serve as a
noose. The vessel is incised, and the electrode
catheter is introduced. After intracardiac posi-
64 The Annals of Thoracic Surgery Vol 29 No 1 January 1980

Sternocleidomastoid

Fig I. Exposure of the external and internal jugular the electrode catheter can be identified on a
veins, with anatomical relationships. roentgenogram and differentiated from im-
plants in which the cephalic or external jugular
tioning of the electrode is achieved, the elec- vein was used.
trode is fixed to the internal jugular vein with
three synthetic nonabsorbable ties, then tun- Results
neled subcutaneously to the pulse generator During introduction and manipulation of the
site. The wound is irrigated with 0.02% kan- catheter, bleeding estimated between 100 and
amycin in normal saline solution and closed 200 ml occurred in 2 patients. No patient re-
with absorbable suture material. The course of quired blood transfusion. Recurrent nerve in-
jury resulting in hoarseness occurred in 1 pa-
tient in whom paralysis of the left vocal cord
Reasons for Use of the lnternal Iugular Vein was documented two months postoperatively
instead of the Cephalic or External by laryngoscopy. Air embolism w a s never a
Jugular Vein in 92 Implants problem clinically. It was observed twice by
External fluoroscopy in the right heart, but the embolized
Reason Cephalic Jugular air was absorbed spontaneously within several
Too small 38 (41%) 22 (24%)
minutes without difficulty and the procedure
Not found 13 (14%) 30 (33%) was resumed.
Not noteda 8 (9%) 19 (20%) In 59 of the 92 implants for which the inter-
Cannulated but could 10 (11Y0) 10 (11%) nal jugular vein was used, the site of the im-
not pass plant had not been employed before for pace-
Used previously and 23 (25%) 10 (11%) maker insertion. Of these 59 patients, 57 had
not reusable
never had a permanent transvenous pacemaker.
Not sought ... 1 (1%)
Two of the 90 patients with an internal jugular
Total 92 92
~ ~~ ~~~
implant died. One of them arrested during the
aNot usable because too small or not found. operative procedure with electromechanical
65 Brodman and Furman: Pacemaker Implantation through Internal Jugular Vein

Fascia There were no central nervous system com-

plications. Fear of thrombosis of the internal
jugular vein after ligation has caused some au-
thors to believe that this vessel should not be
ligated [l,41. They recommend use of a purse-
string suture on the internal jugular vein to
avoid thrombosis despite the observation that
stenosis and thrombosis occur frequently in
tributaries of the superior vena cava that
have a transvenous pacemaker electrode
within the lumen, but rarely cause a problem
clinically [5].
In our experience with ligation and use of the
internal jugular vein for transvenous pacemaker

"I
Fig 2 . Exposure of the internal jugular vein, with ana-
electrode placement the only complications of
consequence directly attributable to the method
were the two episodes of thrombophlebitis
tomical relationships in cross section above the clavicle. of the internal jugular vein and the injury to
(SH = stemohyoid muscle; ST = sternothyroid muscle;
the recurrent laryngeal nerve [2, 33. Thrombo-
SHSCM = sternal head of sternocleidomastoid muscle;
CHSCM = clavicular head of sternocleidomastoid mus- phlebitis of the internal jugular vein resulted
cle; Trach. = trachea; T = thyroid gland; IJ = internal in morbidity only. Permanent disability did re-
jugular vein; OH = omohyoid muscle; EJ = external sult from injury to the recurrent laryngeal
jugular vein; E = esophagus; CS = carotid sheath; V =
vagus nerve; P = phrenic nerve; TCA = transverse nerve, but this complication is avoidable. No
cervical artery; SA = anterior scalene muscle; PL = complications occurred from use of both inter-
platysma; C = carotid artery.) nal jugular veins at different times. These
findings support our decision to continue to
dissociation. In the other patient, a frail old use the internal jugular vein. However, a ve-
woman, a wound infection developed at the nipuncture technique, now under development,
pulse generator site and she died one month to enter the subclavian vein for introduction of
postoperatively. Of particular interest are 2 pa- a permanent pacemaker electrode may reduce
tients who had thrombophlebitis of the internal the necessity of using the external or internal
jugular vein. Marked pain, swelling, erythema, jugular vein.
and tenderness of the lateral aspect of the neck
from clavicle to mandible developed on the
fourth and seventh postoperative day, respec- References
tively. A thrombosed internal jugular vein 1. Chardack Wh4: Cardiac pacemakers and heart
block, in Gibbons' Surgery of the Chest. Third
could be felt beneath the indurated soft tissues. edition. Edited by DC Sabiston, FC Spencer.
Organisms were never isolated from repeat Philadelphia, Saunders, 1976, p 1263
blood cultures. Treatment for approximately 2. Furman S, Escher DJW: Principles and Tech-
one week with warm soaks, heparin, and intra- niques of Cardiac Pacing. New York, Harper &
venously administered antibiotics resolved the Row, 1970, p 120
3. Leininger BJ, Neville WE: Use of the internal
problem. Both patients are alive and well at six
jugular vein for implantations of permanent
months and one and a half years postopera- transvenous pacemakers: experiences with 22 pa-
tively. tients. Ann Thorac Surg 5:61, 1968
Also of interest are 2 patients in whom both 4. Rao G,Zikria EA: Technique of insertion of pac-
internal jugular veins were used as a result of ing electrode through the internal jugular vein. J
multiple procedures for electrode problems and Cardiovasc Surg (Torino) 14:294, 1973
5. Stoney WS, Addlestone RB, Alford WC Jr, et al:
wound infections. Both patients are well at four The incidence of venous thrombosis following
and seven years after ligation of the second long-term transvenous pacing. Ann Thorac Surg
internal jugular vein. 22:166, 1976