Subclavian versus axillary vein puncture for implantation of cardiac electronic devices. A meta-analysis

Abstract

Abstract Background Implantation of CIED has become a daily practice for patients with rhythm disturbances, those with an indication for primary or secondary sudden cardiac death prevention as well as for patients with heart failure and marked ventricular dyssynchrony. Most of the complications observed following implantation seem to be procedure-related. The latter has led many physicians to replace the classic subclavian approach with alternative techniques such as cephalic vein cut-down and axillary vein puncture (AVP). Recent data support that these techniques may be associated with similar success rates and lower adverse events. Purpose This meta-analysis was performed to compare axillary to subclavian vein puncture (SVP) for implantation of cardiac implantable electronic devices (CIED), in terms of safety and efficacy. Methods We searched MedLine, via PubMed, for studies comparing subclavian to axillary vein approach in terms of safety and efficacy. Safety endpoints were considered the incidence of pneumothorax, device related infections and major bleeding events. Efficacy and feasibility were assessed by the incidence of lead failure (lead dislodgement, lead fracture or insulation defects) and the number of successfully cannulated veins, respectively. Studies were judged as eligible if they reported at least one of the predefined outcomes. Effect size was calculated using the risk difference along with the corresponding 95% confidence interval (CI). A random- effects DerSimonian-Laird model was adopted. Results Seven studies fulfilled the inclusion criteria and were included in the final analysis, resulting in 3642 patients (59.1% males) with a pooled mean (SD) age of 66.1 (12.7) years. Axillary vein puncture (AVP) was performed in 45.8% of them. All, but one study, used fluoroscopic guidance (with or without venography) for axillary vein cannulation. The CIED most commonly implanted was a permanent pacemaker (73%). Both techniques resulted in similar percentages of successful cannulations (1066/1099 for AVP and 906/931 for SVP, RD: 0; 95% CI: −0.01–0.01, I2: 0%, Figure 1A). There was a significantly higher risk for pneumothorax with the subclavian approach (RD: 0.02; 95% CI: 0.01–0.03, I2: 49.31%, Figure 2A). No significant differences were observed regarding the incidence of bleeding and infections (Figure 2B, 2C). SVP was also associated with a significantly increased risk for lead failure (RD: 0.01; 95% CI: 0.00–0.03, I2: 48.47%, Figure 1B). Conclusions AVP seems to be a feasible approach for implantation of CIED. Moreover, it seems to be both a more safe and effective choice compared to SVP, as it is associated with reduced risk for pneumothorax and lead failure. More data especially comparing AVP to cephalic cut-down are needed to safely guide the daily practice. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2