Caudal fluoroscopic guidance for the insertion of transvenous pacing leads

Abstract

BackgroundPneumothorax is a well‐recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion.MethodsRetrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography.ResultsThree thousand two hundred fifty‐two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16–102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01).ConclusionCaudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.

Changing the view: Preventing pneumothorax during transvenous pacemaker implantation

“…6 In this issue of Journal of Cardiovascular Electrophysiology, Morton et al describe a large, single-center retrospective analysis of employing caudal 40°angulation rather than conventional antero-posterior (AP) fluoroscopy to guide subclavian vein puncture for insertion of transvenous pacing wires for CIEDs that demonstrates a reduction in pneumothorax rates and use of contrast venography. 7 Although the most employed imaging technique for subclavian vein puncture is straight AP fluoroscopy, the method of adding 40°caudal angulation to standard fluoroscopy was described by Yang et al and suggested reductions in pneumothorax rates by affording the operator a measure of needle depth in relation to important structures such as the pleural space, improving safety. 8 Specifically, the anterior surface of the lung can be better appreciated in this oblique view, and there is greater separation between the clavicle and the first rib, the space through which the puncture needle is advanced to cannulate the subclavian vein.…”

“…In the current paper, although overall complication rates were low, 40°caudal angulation was associated with a 72% lower risk of pneumothorax than AP fluoroscopy, and interestingly, a reduced requirement for contrast venography. 7 A large number of cases were included, totaling 3252 patients (2536 using the caudal technique, and 716 using AP guidance alone), which is a key strength for this paper. The mean age was 71.1 years and 66.7% of patients were male, which is similar to previously published cohorts, and proceduralist experience did not differ significantly between groups.…”