Axillary vein technique for pacemaker and implantable defibrillator leads implantation

Abstract

Different methods for venous access are used for permanent pacemaker or implantable cardioverter defibrillator (ICD), of which subclavian vein puncture technique is the most widely practised. Although this approach is relatively easy to learn, quick and offers high success rates, it may be associated with potential serious acute complications including pneumothorax, emopneumothorax, brachial plexus injury and longer-term complications such as lead fracture, loss of lead insulation and subclavian crush syndrome especially in young patients with ICD leads. Axillary vein approach seems to be a favourable technique not only for the prevention of acute complications but also to reduce lead failure including lead insulation and lead fracture prevention with a consequently better long-term lead survival compared with the classical subclavian approach. Although randomized studies are lacking, recent reports not only evaluated the safety and effectiveness of new fluoroscopic axillary venous puncture technique, but also compared it with the conventional intrathoracic subclavian venous puncture technique for the implantation of leads in permanent pacing. Various techniques of axillary vein puncture have been proposed ranging from a blind percutaneous puncture to the use of different tools such as contrast venography and ultrasound. In this article, we report a case of subclavian crush syndrome, the use of a modified Bellot's technique of axillary vein puncture that we currently use and the potential benefits of axillary vein puncture for pacemaker and ICD leads implantation compared with subclavian approach to avoid acute and long-term lead complications.

Axillary vein puncture using fluoroscopic landmarks: a safe and effective approach for implantable cardioverter defibrillator leads

“…The difference may be explained by the different study population (in our study all patients underwent ICD implantation) and the presence of severe vein spasm in two patients not reported by Antonelli et al We observed that the main cause (4.9 %) of failure was an abnormal course consisting of the vein not crossing the lateral edge of the first rib. Instead, the use of body surface of the second rib as landmark offered a significantly higher (100 %) success rate and a more lateral approach avoiding potential lead entrapment between the clavicle and the first rib, a cause of lead failure during follow-up [10]. Recently, Krahn, in a retrospective case-control study of 133 patients with Fidelis lead fractures, found that a more lateral vein access point is associated with a lower fracture risk [27].…”

“…Subsequently, various different techniques of axillary vein approach have been proposed ranging from a blind percutaneous puncture to the use of different tools such as contrast venography and ultrasound [10,[21][22][23][24][25][26]. Belott [23] described a technique for blind axillary vein puncture using anatomic landmarks by placing the needle tip fluoroscopically over the middle of the first rib prior to needle advancement through the pectoralis major muscle and maintaining this position by adjusting to a steeper needle angle when advancing to touch the rib.…”

“…Furthermore, axillary vein has been demonstrated to be an effective method with less acute complications and less lead failures in the longer term compared with subclavian access, especially for PM implantation [10][11][12][13][14][15][16][17][18][19]. However, data on axillary vein approach for ICD implantation are limited.…”

“…However, it may be associated with potentially serious acute complications, including pneumothorax, hemothorax, and brachial plexus injury [2,3], or longer-term complications such as lead fracture, loss of lead insulation, and subclavian crush syndrome, especially with ICD leads [4][5][6][7][8][9][10].…”

Extrathoracic subclavian‐axillary vein location and morphological features over the first rib for pacemaker and defibrillator lead implantation

“…The axillary vein is a common venous access point for placing a pacemaker or ICD lead during implantation of cardiac electronic devices and was first suggested by Byrd et al . Since then, various techniques have been recommended, ranging from venous puncture to use of several instruments, such as contrast venography or ultrasound . This approach has been preferred by many authors over the classical subclavian vein approach due to the possible reduced risk of pneumothorax and late lead fracture compared to subclavian vein access …”