Is it safe to place a central line on the left side in a patient with a permanent pacemaker (artificial cardiac pacemaker)?

Central Line Placement on the Left Side in Patients with Permanent Pacemakers

In patients with permanent pacemakers, placing a central line on the left (ipsilateral) side is generally safe and can be performed when the contralateral (right) arm is not amenable to insertion, though preferential placement by interventional radiology may be appropriate in these cases. 1

Key Guideline Recommendations

When Left-Sided Placement is Appropriate

• For patients with permanent pacemakers or defibrillators, the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) panel rated preferential placement by an interventional radiologist as appropriate when the contralateral arm is not amenable to insertion. 1

• The standard recommendation is to avoid the ipsilateral side when possible to preserve venous access and reduce theoretical risks of lead dislodgment or venous thrombosis. 1

• However, when the right side is unavailable (due to prior thrombosis, existing access, or anatomical considerations), left-sided placement can proceed with appropriate precautions. 1

Supporting Clinical Evidence

Safety Data from Real-World Practice

• A retrospective study of 600 hemodialysis catheter placements over 10 years found that 20 pacemakers or ICDs were present on the same side as newly placed central catheters in the ipsilateral jugular vein, with no patients exhibiting malfunction, dislodgment of pacemaker leads, or evidence of upper extremity venous obstruction. 2

• This study specifically demonstrated that placement of large-bore catheters (hemodialysis catheters) in the internal jugular vein ipsilateral to pre-existing pacemaker leads is safe in clinical practice. 2

Technical Considerations for Left-Sided Placement

Optimal Venous Access Sites

• For transvenous procedures in patients with cardiac devices, the right internal jugular vein and left subclavian vein are considered optimal placement sites. 3

• The left subclavian approach may be preferable to left internal jugular when a left-sided pacemaker is present, as it provides a different trajectory and reduces proximity to the device pocket. 3

Catheter Tip Positioning

• The catheter tip should terminate in the lower one third of the superior vena cava or cavoatrial junction to limit thrombosis risk. 1

• Radiographic verification of catheter tip position is appropriate after bedside placement to ensure proper positioning and avoid complications. 1

Procedural Precautions

• Use ultrasound guidance for venous access to minimize complications and improve first-pass success. 3

• Consider fluoroscopic guidance or interventional radiology consultation for complex cases, particularly when anatomical variations or multiple prior access attempts exist. 1

• Avoid excessive manipulation near the pacemaker pocket and leads during catheter advancement. 2

Common Pitfalls and How to Avoid Them

Risk of Lead Dislodgment

• While theoretical concerns exist about dislodging pacing wires, clinical evidence suggests this risk may be overstated when proper technique is used. 2

• Gentle catheter advancement and avoiding aggressive manipulation near the device pocket minimize this risk. 2

Venous Thrombosis Considerations

• Left-sided PICC placements are associated with higher risk of deep vein thrombosis compared to right-sided placements. 4

• Use single-lumen catheters when possible to reduce thrombosis risk, as risk increases with the number of catheter lumens. 4, 5

• Consider the smallest gauge catheter appropriate for the clinical indication. 1

Device Interference

• Modern pacemakers and ICDs are well-shielded, and central line placement does not typically interfere with device function when proper technique is employed. 2

• Post-procedure device interrogation may be considered if there are concerns about lead integrity or device function, though routine interrogation is not necessary. 2

Alternative Approaches When Standard Access is Unavailable

When Both Sides Are Compromised

• In patients with bilateral venous occlusion or limited central venous access, alternative approaches such as transhepatic venous access have been successfully used for pacemaker lead placement and could theoretically be considered for central lines. 6

• Femoral venous access remains an option for temporary central access when upper extremity sites are unavailable or contraindicated. 3

Clinical Algorithm for Decision-Making

1. First choice: Attempt contralateral (right-sided) access if available and patent 1

2. If right side unavailable: Proceed with left-sided placement using:

   • Ultrasound guidance for venous access 3
   • Consider interventional radiology consultation 1
   • Use left subclavian approach when feasible over left internal jugular 3

3. Post-placement: Verify tip position radiographically 1

4. Ongoing care: Follow standard central line maintenance protocols with attention to thrombosis prevention 4, 5