Peel-away sheaths revolutionized insertion of leads after punctured access. A fact that made cut-down essential in the past was the lack of suitable removal sheath. Peel-away sheaths facilitated venous access via seldinger technique and helped popularize punctured venous access for pacing.
Peel-away Sheath : A revolution in venous access for pacing
In pacing, sheath insertion should be undertaken only after the ensuring that the guide-wire is in the venous system (Subclavian vein – SVC – RA – IVC). Sheaths should never be passed if there is a doubt as to where the wire is.
Once the guide-wire is in place (venous system), the sheath is glided along the guide wire into the vein. Before doing so, the sheath system must be checked and flushed. The system consists of a central dilator (which gives strength and stability to create a path out of soft tissue) and surrounding peel-away soft sheath. The dilator should be partially taken out and re-fitted to ensure that they are not stuck and the sheath should be flushed with heparinized saline before insertion. For standard bradycardia pacing, the dilator size is 7 French and for ICD leads it is 9 French.
Insertion of Peel-away Sheath
Before inserting the sheath, one must ensure that the guidewire is at the floor of the pocket – i.e. its is seen to emerge from the pocket floor muscle. If it is not, the future sheath entry point and subsequent lead entry point would be more superficial and this may cause the lead to erode to the surface much later on. The best way is to dissect tissues surround the guidewire and take it down to the pocket floor (see video below) before inserting the sheath.
If you find it difficult to send even a large dilator, then its best to abandon the puncture and do a fresh puncture slightly lateral to the existing guide-wire as your original puncture may have been too medial causing bony impingement. The first guide-wire will serve as a guide and therefore it should be removed only after the new guide-wire has been inserted correctly.