Axillary vein access using ultrasound guidance, Venography or Cephalic Cutdown—What is the optimal access technique for insertion of pacing leads?

Abstract

Cardiac Implantable Electronic Device implantation is associated with a small risk for pocket hematoma partially due to inadvertent axillary/subclavian artery puncture, pneumothorax and infection and more rarely thoracic duct injury and brachial plexus injury and in the long term lead fracture. 1 The traditional anatomic based approach for subclavian vein puncture is particularly associated with an increased risk. 2,3 These risks could be reduced by accessing the axillary vein and not the subclavian vein using a venogram based approach, [4][5][6][7] or by an ultrasound based approach for lead insertion 4,[6][7][8] or cephalic vein cut down. [4][5][6][7] Most implanters prefer cephalic cutdown as their initial approach. 9 We argue that an ultrasound guided axillary vein approach also should be considered for all such procedures. | CEPHALI C VEIN CUTDOWNCephalic cutdown has been suggested to be the preferred venous access to reduce the risk for lead crush and to avoid needle stick injury to surrounding structures. 10 However it is only suitable for some patients 11 due to small vein size, tortuosity, difficulty surgically isolating the vein and in some cases vein absence. 10 It is approached with surgical dissection of the deltopectoral groove, the vein lying between the pectoralis major and deltoid muscles (Figure 1). The vein is blunt dissected free from the surrounding structures and cannulated either with an intravenous (IV) cannula and glidewire or venotomy, a vein pick and then passage of a wire or lead down the vein lumen. In some cases, venography also is

Efficacy and safety of axillary vein puncture real-time guided by roadmap fluoroscopy in cardiac pacemaker implantation

“…Our shorter time to axillary venous access in the roadmap application reinforces the ndings of previous study which demonstrated in nonrandomized fashion a shorter time to position the leads in the superior vena cava using the ultrasound -guided axillary approach. [22,23] From a clinical point of view, longer procedure duration has been associated with increased infection risk, indicating that shorter duration interventions and lower incidence of complications, in addition to enabling quicker operating room turnover, may lead to better infective outcomes.…”

Efficacy and safety of axillary vein puncture real-time guided by roadmap fluoroscopy in cardiac pacemaker implantation

“…Our shorter time to axillary venous access in the roadmap application reinforces the findings of previous study which demonstrated in nonrandomized fashion a shorter time to position the leads in the superior vena cava using the ultrasound -guided axillary approach. [22,23] From a clinical point of view, longer procedure duration has been associated with increased infection risk, indicating that shorter duration interventions and lower incidence of complications, in addition to enabling quicker operating room turnover, may lead to better infective outcomes.…”

Subclavian Crush Syndrome and Inappropriate Shocks in Patient With Implantable Cardioverter Defibrilator

“…Fluoroscopic guided axillary vein cannulation has a 50% shorter venous access time (5.7 minutes) and 30% shorter total procedural time (34 minutes) compared to a cephalic cut-down, according to a prospective randomized study published in 2017. [12,13].…”