Use of the transfemoral access approach for cardiac stimulation device implantation when the superior venous approach is not feasible: A single-centre twenty-year series

Main Article Content

Juan J. Garcia Guerrero, MD Joaquín Fernández de la Concha Castañeda, MD Antonio Chacón Piñero, MD


Background: When permanent cardiac stimulation device implantation via superior venous access (i.e., cephalic, axillary or subclavian veins) is not possible or advisable, safe and feasible surgical alternatives must be used. The transfemoral approach is relatively unknown; therefore, it is seldom used and studied. This single-centre study analysed the 20-year outcomes of patients who underwent implantation using a transfemoral implantation approach.

Methods: Data on the implantation procedure (indication, approach, lead and pacemaker models, complications), patient characteristics (age, sex, medications, comorbidities), and follow-up were analysed for all patients who underwent permanent cardiac stimulation device implantation using the transfemoral approach between June 2001 and December 2021.

Results: A permanent cardiac stimulation device was implanted using the transfemoral approach in 66 patients (mean age, 76 years [range: 45-96], 40 [60%] men). The most frequent indication was atrioventricular block, associated with sinus rhythm in 36 patients and atrial fibrillation in 11 patients. The mean implantation time was 61 min (range: 20-210), and the mean fluoroscopy time was 7.9 min (range: 0.2-87). The minimum follow-up period was one year (December 2022), with a mean of 60 months [range: 2-180]). Overall, 26 patients (42%) were treated with oral anticoagulants postimplantation. No deaths, septic episodes, or severe complications were associated with the procedure in the short or long term. Follow-up data were available for 64 patients, of whom 52 (81%) died during follow-up (mean age, 84 years [range: 55-101]). No deaths were associated with the use of the transfemoral technique.

Conclusions: Permanent cardiac stimulation device implantation using the transfemoral access approach is feasible and straightforward for an experienced implant surgeon. The outcomes of systems implanted by the transfemoral access approach were comparable to those of systems implanted by the superior venous approach, and no severe complications were observed at the 20-year follow-up.

Keywords: transfemoral approach, permanent cardiac stimulation devices, iliofemoral, venous occlusion

Article Details

How to Cite
GUERRERO, Juan J. Garcia; CASTAÑEDA, Joaquín Fernández de la Concha; PIÑERO, Antonio Chacón. Use of the transfemoral access approach for cardiac stimulation device implantation when the superior venous approach is not feasible: A single-centre twenty-year series. Medical Research Archives, [S.l.], v. 12, n. 1, jan. 2024. ISSN 2375-1924. Available at: <>. Date accessed: 03 mar. 2024. doi:
Research Articles


1. Mansour K, Dorney ER, Tyras DH et al. Cardiac pacemakers: Comparing epicardial and perivenous pacing. Geriatrics.1973;28:151-155.
2. El Gamal M and Van Gelder B. Preliminary experience with the Helifix electrode for transvenous atrial implantation. PACE. 1979;2:444-454. doi: 10.1111/j.1540-8159.1979.tb05220.x
3. Ellestad MH, Caso R and Greenberg PS. Permanent pacemaker implantation using the femoral vein: a preliminary report. PACE. 1980;3:418-423. doi: 10.1111/j.1540-8159.1980.tb05250.x
4. Ellestad MH and French J. Iliac vein approach to permanent pacemaker implantation. PACE. 1989;12:1030-1033. doi: 10.1111/j.1540-8159.1989.tb01921.x
5. Mathur G, Stables H, Heaven D, et al. Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach. Europace. 2001;3:56-59. doi: 10.1053/eupc.2000.0135
6. Costa R, Martinelli Filho M, Tetsuji Tamaki W, et al. Transfemoral pediatric permanent pacing: long term results. PACE. 2003;26:487-491. doi: 10.1046/j.1460-9592.2003.00078.x
7. Moriña-Vázquez P, Roa-Garrido J, Fernández Gomez JM, et al. Direct left ventricular endocardial pacing: an alternative when traditional resynchronization via coronary sinus is not feasible or effective. PACE. 2013;36:699-706. doi: 10.1111/pace.12125
8. García Guerrero JJ, Fernández de la Concha J, Fernandez Mora G, et al. Permanent transfemoral pacemaker: a single-center series performed with an easier and safer surgical technique. PACE. 2005;28:675-679. doi: org/10.1111/j.1540-8159.2005.00145.x
9. García Guerrero JJ, Fernández de la Concha Castañeda J, Doblado Calatrava M, et al. Transfemoral access when superior venous approach is not feasible equals overall success of permanent pacemaker implantation. Ten-year series. PACE. 2017;40:638-643. doi: org/10.1111/pace.13082
10. Leal del Ojo JL, Delgado Jimenez C, Jimenez Vilches P, et al. Absence of the superior vena cava: difficulties for pacemaker implantation. PACE. 1999;22:1103-1105. doi: 10.1111/j.1540-8159.1999.tb00580.x
11. Pinski SL and Bredikis A. Defibrillator implantation via the iliac vein. PACE. 2000;23:1315-1317. doi: org/10.1111/ j.1540-8159.2000.tb00953.x
12. Giudici M, Paul DL and Meierbachtol CJ. Active-can implantable cardioverter defibrillator placement from a femoral approach. PACE. 2003;26:1297-1298. doi: 10.1046/j.1460-9592.2003.t01-1-00185.x
13. Perzanowski C, Timothy P, McAfee M, et al. Implantation of implantable cardioverter-defibrillators from an iliofemoral approach. J Cardiovasc Electrophysiol. 2004;11:155:159. doi: 10.1023/B:JICE.0000042355.73042.25
14. Moriña-Vázquez P, Barba-Pichardo R, Venegas Gamero J et al. Implante de un desfibrilador biventricular con estimulación endocárdica transeptal de ventrículo izquierdo vía venosa femoral. Rev Esp Cardiol. 2009;62:1503-1505.
15. Tereno Valente B, Conceição JM, Nogueira da Silva M, et al. Femoral approach: An exceptional alternative for permanent pacemaker implantation. Rev Port Cardiol. 2014;33:311.e1-311.e5. doi: org/10.1016/ j.repce.2014.02.003
16. Ipek EG, Guray U, Demirkan B, et al. Infections of implantable cardiac rhythm devices: predisposing factors and outcome. Acta Cardiol. 2012:67:307-310. doi: 10.2143/AC.67.3.2160719
17. Silvestre García J, Aguado García JM and García Guerrero JJ. Infecciones en el sistema de marcapasos. Extracción de electrodos. Estimulación permanente por vía femoral. Rev Esp Cardiol. 2007;7(Supl.G):145-156. doi: org/10.1016/S1131-3587(07)75266-4
18. Seow S, Lim T, Singh D, et al. Permanent pacing in patients without upper limb venous access: a review of current techniques. Heart Asia. 2014;6:163-166. doi: 10.1136/heartasia-2014-010546
19. Ramesh V, Gaynor JW, Shah MJ, et al. Comparison of left and right atrial epicardial pacing in patients with congenital heart disease. Ann Thorac Surg. 1999;68:2314-2319. doi: 10.1016/s0003-4975(99)01053-x
20. Mela T, McGovern BA, Garan H, et al. Long-term infection rates associated with the pectoral versus abdominal approach to cardioverter-defibrillator implants. Am J Cardiol. 2001;88:750-753. doi: 10.1016/s0002-9149(01)01845-8
21. Sperzel J, Defaye P, Delnoy PP, et al. Primary safety results from the LEADLESS Observational Study. Europace. 2018;20:1491-1497. doi: 10.1093/europace/eux359
22. Griffiths S, Behar J, Kramer DB, et al. The long-term outcomes of cardiac implantable electronic devices implanted via the femoral route. PACE. 2022;1-10. doi: 10.1111/pace.14449
23. Kron J, Herre J, Graham E, et al. Lead- and device-related complications in the antiarrhythmics versus implantable defibrillators trial. Am Heart J. 2001;141:92-98. doi: 10.1067/mhj.2001.111261
24. Sanders P, Farouque O, Ashby DT, et al. Effect of anticoagulation on the occurrence of deep venous thrombosis associated with temporary transvenous femoral pacemakers. Am J Cardiol. 2001;88:798-800. doi: 10.1016/s0002-9149(01)01857-4
25. Nolewajka AJ, Goddard MD and Brown TC. Temporary transvenous pacing and femoral vein thrombosis. Circulation. 1980;62:646-650. doi: 10.1161/01.cir.62.3.646
26. García Guerrero JJ, Fernández de la Concha J, López Quero D, et al. Lower incidence of venous thrombosis with temporary active-fixation lead implantation in mobile patients. Europace. 2010;12:1604-1607. doi: 10.1093/europace/euq262
27. Da Silva KR, Costa R, Rached RA, et al. Warfarin prevents venous obstruction after cardiac devices implantation in high-risk patients: partial analysis. Rev Bras Cir Cardiovasc. 2008;23:542-549. doi: 10.1590/s0102-76382008000400015
28. Van der Mee-Marquet N, Achard A, Mereghetti L, et al. Staphylococcus lugdunensis infections: High frequency of inguinal area carriage. J Clin Microbiol. 2003;41:1404-1409. doi: 10.1128/JCM.41.4.1404-1409.2003
29. Lekkerkerker JC, Van Nieuwkoop C, Trines A, et al. Risk factors and time delay associated with cardiac device infections: Leiden device registry. Heart. 2009;95:715-720. doi: 10.1136/hrt.2008.151985
30. Saeed O, Gupta A, Gross JN et al. Rate of cardiovascular implantable electronic device (CIED) re-extraction after recurrent infection. PACE. 2014;37:963-968. doi: 10.1111/pace.12407
31. Martin A, and Lever N. Permanent transfemoral pacing: making things easier. Heart, Lung and Circulation. 2021;30:e41-e44. doi:10.1016/j.hlc.2020.07.014