What are the considerations for central line placement in patients with a permanent pacemaker (PPM)?

Central Line Placement in Patients with Permanent Pacemakers

Central line placement in patients with permanent pacemakers (PPMs) should be performed on the contralateral side to the pacemaker to avoid complications related to venous stenosis and lead damage.

Anatomical Considerations

• The presence of a permanent pacemaker creates important anatomical considerations when planning central venous access due to the risk of venous stenosis and potential lead damage 1
• Central vein stenosis is an underestimated complication of permanent pacemaker placement that can lead to serious problems if additional venous access is required on the ipsilateral side 2
• Pacemaker leads typically occupy space within the central veins (subclavian, innominate, superior vena cava), which can limit the available space for additional catheters 3

Preferred Access Sites

• The contralateral side to the pacemaker is the preferred site for central line placement to avoid potential complications 2, 1
• If the pacemaker is on the left side, right-sided access (right internal jugular or right subclavian) should be used for central line placement 1
• If the pacemaker is on the right side, left-sided access (left internal jugular or left subclavian) should be used for central line placement 1

Risks of Ipsilateral Access

• Placing a central line on the same side as a pacemaker carries several risks:
  • Increased risk of venous stenosis or occlusion, which can lead to upper extremity edema 2
  • Potential for pacemaker lead dislodgement during catheter insertion 4
  • Reduced success rate for catheter placement due to limited venous space 5
  • Potential interference with future pacemaker lead revisions or upgrades 5

Special Circumstances

• In cases where contralateral access is not possible (e.g., bilateral pacemakers, contralateral venous occlusion), alternative approaches may be considered:
  • Femoral venous access as a temporary measure 5
  • Endovascular recanalization of occluded veins to create access for central line placement 5
  • Ultrasound-guided access to minimize the risk of lead damage 4

Management Algorithm

1. Assess pacemaker location: Determine which side the pacemaker is implanted on through physical examination and chest imaging 1
2. Choose contralateral access: Select the internal jugular or subclavian vein on the side opposite to the pacemaker 2, 1
3. Use ultrasound guidance: Employ ultrasound for vein localization and to visualize pacemaker leads if ipsilateral access is unavoidable 4
4. Consider alternative sites: If both subclavian/jugular approaches are compromised, consider femoral access or other central veins 5

Exceptions to Contralateral Placement

• While generally avoided, some studies suggest that ipsilateral placement may be safe in certain circumstances:
  • A retrospective review of 600 hemodialysis catheters found no complications when placing catheters ipsilateral to pacemakers in 20 cases 1
  • However, this remains controversial and contralateral placement is still recommended as the standard approach 2

Temporary Pacing Considerations

• For patients requiring temporary transvenous pacing:
  • The right internal jugular vein and left subclavian vein are optimal placement sites 4
  • Temporary pacing wires can be placed via femoral access if needed 6
  • The risk of infectious complications in permanent pacemaker placement is increased in patients who have had a temporary pacing wire before permanent implant 6

Conclusion

When placing central lines in patients with permanent pacemakers, the safest approach is to use the contralateral side to avoid potential complications related to venous stenosis and lead damage. Ultrasound guidance should be employed whenever possible, especially if ipsilateral access cannot be avoided.