Axillary Vein Puncture Research Articles

Ultrasound-Guided Axillary Access Using a Micropuncture Needle Versus Conventional Cephalic Venous Access for Implantation of Cardiac Devices: A Single-Center Randomized Trial

(1) Background: Ultrasound-guided axillary (USAX) vein puncture is a relatively new method to obtain venous access for the implantation of cardiac implantable electronic devices (CIED). However, its use is limited as most of the operators are not familiar with this technique. Our aim was to investigate the safety and efficacy of the USAX compared with the traditional cephalic vein dissection for venous access in CIED implantation. (2) Methods: This was a single-center, randomized, controlled, superiority trial. A total of 114 patients were randomized (1:1 ratio) to either USAX (u/s axillary group; 59 patients) or cephalic vein access (cephalic group; 55 patients). The primary study endpoint was defined as successful placement of all leads via the chosen access. Secondary study endpoints included time from local anesthetic injection to lead advancement in the SVC, total procedure time (skin to skin), procedure-related complications and pain perception. (3) Results: USAX was superior to cephalic access in terms of primary endpoint (OR: 4.3, 95% CI: 1.3, 14.0; p = 0.012). Total procedure duration was higher in the cephalic group (55.15 ± 16.62 vs. 48.35 ± 12.81 min, p = 0.017) but there was neither a significant difference in fluoroscopy time (p = 0.872) nor in total radiation dose (p = 0.815). The level of pain was higher in the cephalic group (p = 0.016), while the rates of complications were similar in both groups (p > 0.05). (4) Conclusion: USAX was superior to cephalic access regarding success rate, total procedure duration and level of pain, while having no difference in complication rates.

Ultrasound-guided versus fluoroscopy-guided axillary vein puncture for cardiac implantable electronic device implantation: a meta-analysis enrolling 1257 patients.

Ultrasound-guided (Echo-AVP) and Fluoroscopy-guided Axillary Vein Puncture (Fluoro-AVP) are both acknowledged as safe and effective techniques for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile. Therefore, we performed a meta-analysis to evaluate the efficacy and safety of Echo-AVP versus Fluoro-AVP for CIEDs implantation. We systematically searched Medline, Embase and Cochrane electronic databases up to May 15th, 2024, for studies that evaluated the efficacy and safety of Echo-AVP and Fluoro-AVP reporting at least one clinical outcome of interest. The primary efficacy endpoint was acute procedural success and the primary safety endpoint was a composite endpoint of pneumothorax, pocket hematoma/bleeding, pocket infection and inadvertent arterial puncture. The effect size was estimated using a random-effect model as Odds Ratio (OR) and Mean Difference (MD) with relative 95% Confidence Interval (CI). Overall, 4 studies were included, which enrolled 1257 patients (Echo-AVP: 373 patients; Fluoro-AVP: 884 patients). Echo-AVP led to a significant reduction in the primary safety endpoint (OR: 0.41; p = 0.0009), risk of inadvertent arterial puncture (OR: 0.29; p = 0.003) and fluoroscopy time ( MD: -105.02; p = 0.008). No differences were found between Echo-AVP and Fluoro-AVP for acute procedural success (OR: 0.77; p = 0.27), pneumothorax (OR: 0.66; p = 0.60), pocket hematoma/bleeding (OR: 0.68; p = 0.30), pocket infection (OR: 0.66; p = 0.60), procedural time (MD: 1.99; p = 0.65), success rate at first attempt (OR: 1.25; p = 0.34) and venous access time (MD: -0. 25; p = 0.99). Echo-AVP proved to reduce significantly the primary safety endpoint, inadvertent arterial puncture and fluoroscopy time compared to Fluoro-AVP.

Association between BMI and success of transaxillary venous port implantation: A retrospective cohort study.

Totally implanted venous access device are widely used for long-term chemotherapy in cancer patients. Previous studies have only focused on the analysis of complications associated with infusion port implantation, ignoring the causes of unsuccessful infusion port implantation. The purpose of this study was to investigate the association between body mass index (BMI) and the success rate of transaxillary intravenous port implantation in breast cancer patients. To review 361 breast cancer patients who underwent intravenous port implantation from January 2021 to September 2021. Baseline data, and surgical data were collected from the patients, and the success rate of puncture of the axillary vein was recorded. The logistic regression analysis and smoothed curve fitting were used to assess the relationship between BMI and the success rate of axillary venipuncture. In addition, subgroup analyses were performed to explore potential interactions. Under ultrasound guidance, 67.3% of patients (243/361) had an infusion port implanted by axillary vein puncture. There was a roughly linear relationship between BMI and the success rate of axillary venipuncture. In the multiple regression equation, BMI was significantly and negatively associated with the success rate of axillary venipuncture (OR = 0.83; 95% CI = 0.77-0.89; p < 0.001). Stratified analysis showed that the relationship between BMI and the success rate of axillary venipuncture was stable and unaffected by other variables. The higher the patient's BMI, the higher the chance of difficult axillary venipuncture or failed cannulation.

Feasibility and outcomes of ultrasound-guided transcutaneous access to the axillary vein for implantation, revision, and upgrade of cardiac electronic devices

Abstract Background Implanting leads for cardiac implantable electronic devices (CIED) requires venous access. Venous access is commonly established through the cephalic and subclavian vein. For CIED upgrades or revisions, the preferred cephalic vein access is often not viable. Several reports suggest that fluoroscopy-guided axillary vein puncture may reduce thoracic complications. Purpose This study reports on procedural outcomes of ultrasound-guided axillary vein access for CIED implantation, revision, or upgrade in a large tertiary care centre. Outcomes were compared to the traditional subclavian vein approach. Methods This retrospective, single-center non-randomized study, conducted from January 2021 to August 2023, analyzed patients undergoing CIED implantation, revision, or upgrade. Axillary access, initially introduced by one operator, was increasingly adapted by additional operators. The axillary access was obtained by ultrasound-guided visualization of the axillary vein at the deltopectoral groove (Figure 1A and B). Subsequently, the wire(s) were transcutaneously inserted. An adjacent skin incision allowed for threading the wire(s) followed by standard lead implantation (Figure 1C). The study evaluated the acute success of each venous access method and the incidence of adverse events. Those were defined as pneumothorax, hemothorax, and pocket hematoma. An intention-to-treat analysis was performed. A p-value assessed the comparative outcomes between the axillary and subclavian access methods. Results In this study, 986 patients (mean age 74, IQR 64-82 years, 35% women) underwent CIED implantation, revision, or upgrade with 1636 lead implants. Axillary access was used in 578 patients with 532 (92%) successful implantations. Subclavian access yielded a higher success rate with 394/408 patients (97%) (p=0.003). For device upgrades or revisions specifically, axillary access was successful in 68/79 patients (86%), versus 44/47 patients (94%) with subclavian access (p=0.193). Acute complications were less frequent with axillary access (0.3%, 2/578 patients) and consisting of two cases of pneumothorax requiring intervention. In CIED implantations via subclavian access, complications occurred in 17/408 patients (4.2%) (p&amp;lt;0.001) including pneumothorax in 12 patients (2.9%, with 2% requiring intervention), hemothorax in three patients (0.7%), and pocket hematoma in two patients (0.5%). No additional complications were observed in the axillary group. Conclusion The implementation of transcutaneous, ultrasound-guided axillary access for CIED implantations, revisions and upgrades in a major CIED training centre is feasible. Complication rates were low compared to subclavian venous access.Figure 1

The axillary vein puncture for implantable cardiac defibrillator implantation: 14 years of experience. Analysis of the results

BackgroundAxillary vein puncture (AVP) is a valid alternative to Subclavan vein puncture for leads insertion in cardiac implantable electronic device implantation, that may reduce acute and delayed complications. Very few data are available about ICD recipients.A simplified AVP technique is described. MethodsAll the patients who consecutively underwent “de novo” ICD implantation, from March 2006 to December 2020 at the University of Verona, were considered.Leads insertion was routinely performed through an AVP, according to a simplified technique. Outcome and complications have been retrospectively analyzed. ResultsThe study population consisted of 1711 consecutive patients. Out of 1711 patients, 38 (2.2%) were excluded because they were implanted with Medtronic Sprint Fidelis lead.Out of 1673 ICD implantations, 963 (57.6%) were ICD plus cardiac resynchronization therapy, 434 (25.9%) were dual-chamber defibrillators, and 276 (16.5%) were single-chamber defibrillators, for a total of 3879 implanted leads. The AVP success rate was 99.4%. Acute complications occurred in 7/1673 (0.42%) patients. Lead failure (LF) occurred in 20/1673 (1.19%) patients. Comparing the group of patients with lead failure with the group without LF, the presence of three leads inside the vein was significantly associated with LF, and the multivariate analysis confirmed three leads in place as an independent predictor of LF. ConclusionAVP, according to our simplified technique, is safe, effective, has a high success rate, and a very low complication rate. The incidence of LF was exceptionally low.The advantages of AVP are maintained over time in a population of ICD recipients.

Precise Terminology and Specified Catheter Insertion Length in Ultrasound-Guided Infraclavicular Central Vein Catheterization.

Background and Objectives: As the latest research encourages the ultrasound-guided infraclavicular central venous approach, due to the lateral puncture site displacement, in comparison to the anatomical landmark technique based on subclavian vein catheterization, the need to re-calculate the optimal catheter insertion length and possibly to rename the punctuated vessel emerges. Although naming a particular anatomical structure is a nomenclature issue, a suboptimal catheter position can be associated with multiple life-threatening complications and must be avoided. The main study objective is to determine the optimal catheter insertion length by the most proximal ultrasound-guided, in-plane infraclavicular central vein approach, to compare results with the anatomical landmark technique based on subclavian vein catheterization and to clarify the punctuated anatomical structure. Materials and Methods: 109 patients were enrolled in this study. All procedures were performed according to the same catheterization protocol. In order to determine optimal insertion length, chest X-ray scans with an existing catheter were performed. The definition of punctuated vessel was based on computer tomography and evaluated by radiologists. Independent predictors for optimal insertion length were identified, prediction equations were generated. Results: The optimal catheter insertion length is approximately 1.5 cm longer than estimated by Pere's formula and can be accurately calculated based on anthropometric data. Computed tomography revealed: five cases with subclavian vein puncture and three cases with axillary vein puncture. Conclusions: Even the most proximal ultrasound-guided infraclavicular central vein access does not guarantee subclavian vein catheterization. A more accurate term could be infraclavicular central venous access, with the implication that the entry point could be through either subclavian or axillary veins. The optimal insertion length is approximately 1.5 cm deeper than the length determined for the anatomical landmark technique based on subclavian vein catheterization.

Vascular access in cardiac implantable electronic devices: a systematic review and network meta-analysis

Abstract Background Despite the increasing number of cardiac implantable electronic devices (CIED) implantations worldwide, gaps in the evidence base on the optimal venous access to perform the procedure still exist and direct comparisons of different techniques are lacking. Purpose The aim of this study was to compare the acute and long-term safety and efficacy of the three main vascular access modalities (i.e. subclavian vein puncture [SVP], cephalic vein cut-down [CVC], axillary vein puncture [AVP]) used during CIEDs implantations. Methods A systematic review of the literature and network meta-analysis were performed searching Pubmed/MEDLINE databases for relevant articles using the following search strategy, without language restrictions: ((cardiac implantable device) OR (pacemaker) OR (ppm) OR (defibrillator) OR (icd) OR (resynchronization) OR (crt)) AND ((venous access) OR (subclavian) OR (axillary) OR (cephalic)). Randomized and non-randomized studies comparing one or more of the outcomes of interest, between at least two discernible groups (SVP, CVC and AVP), were included in the present analysis and SVP competitive arm was used as the reference group. The primary endpoints were safety outcomes, which included: 1) pneumothorax, 2) pocket haematoma, 3) lead failure, including both acute (dislodgment) and chronic (fracture, subclavian crush syndrome) events, 4) infective complications. Success rate, defined either by successful cannulation of the vein or by successful lead placement was a secondary outcome. Results Forty studies (33, 83% non-randomized) were selected and a total of 166782 patients (median age 69.2 years, 65.2% males) followed up for a median of 18 months (IQR 11-51) were included. Both AVP and CVC showed a significant reduction in the risk of pneumothorax compared to SVP (AVP: OR 0.12, 95% CI 0.05-0.28; CVC: OR 0.18, 95% CI 0.15-0.22) but no significant differences between treatment arms concerning bleedings (AVP: OR 1.11, 95% CI 0.52; 2.37; CVC OR 1.16, 95% CI 0.60; 1.88) or infective complications (AVP: OR 1.00, 95% CI 0.47- 2.14; CVC OR 0.67, 95% CI 0.31-1.44) were observed. Compared to SVP, AVP was significantly superior concerning the risk of lead failure (OR 0.42, 95% CI 0.27-0.67) while CVC showed a nearly statistically significant reduction in risk of lead complications (OR 0.73, 95% CI 0.52-1.02), see figure 1. Success rate did not differ significantly between treatments arms albeit CVC showed a trend towards a higher risk of need for alternate venous access compared to AVP (3.56, 95% CI 0.89-14.21). Conclusions Considering the lower risk of pneumothorax and lead failure, AVP and CVC should be preferred over SVP to achieve venous access during CIEDs implantation taking into account the higher success rates associated with AVP.Figure 1

Complications according to intrathoracic versus extrathoracic venous access for cardiac device implantation: results from the PLACE (Planning Lead Access for Cardiac Electrostimulation) study

Abstract Background and Aims The choice of the vascular access for cardiac pacing devices (CIED) implant may impact on patients outcome. Recent studies and consensus documents encourage the use of an extra-thoracic access to prevent adverse events. In this large, multicenter, retrospective study we report the impact of leads access on post-procedural outcome. Methods Consecutive patients receiving a CIED from 2008 to 2019 in 4 high-volume Italian hospitals were enrolled. Short- and long-term complications (i.e. pneumothorax, cardiac tamponade, pocket decubitus, pocket hematoma, lead dislodgement, lead failure) were collected and their relationship with the type of vascular access (extra- vs intra-thoracic, i.e. cephalic vein/extra-thoracic axillary vein vs subclavian vein puncture) was analyzed. Primary endpoint was the occurrence of at least one complication during follow-up. Results A total of 4,443 patients were enrolled; 3,374 (75.9%) received a pacemaker (PM) and 1,069 (24.1%) an implantable cardioverter defibrillator (ICD). Mean follow-up was 1,630±1,010 days. At least one complication occurred in 7.6% of patients. At multivariate Cox regression analysis, adjusted for baseline confounders, the presence of structural heart disease (HR 1.59, 95%CI 1.21-2.10; p=0.001), anticoagulant therapy at implantation [HR 1.31, 95%CI 1.0004-1.71; p=0.05) and female gender (HR 0.78, 95%CI 0.63-0.98; p=0.03) were associated with the primary outcome measure. Extra-thoracic access did not reduce the risk of complications compared to intra-thoracic access (HR 0.97, 95%CI 0.76-1.25 p=0.81). The use of both accesses in the same patient conferred a significant increase in the risk of complications (HR vs single approach:1.95, 95%CI 1.41-2.69; p &amp;lt;0.001). Conclusions The choice of a different vascular access (intra- vs extra-thoracic) does not impact on post-procedural complications in patients receiving CIED. In particular, the intra-thoracic subclavian vein puncture by experienced operators is not related to a poorer outcome. The need for both types of access in the same patient (i.e. increased procedure complexity) increases the risk of post-procedural complications.Graphical abstract

Feasibility of Ultrasound-Guided Axillary Vein Puncture under Valsalva Maneuver for Diagnostic and Cardiovascular Interventional Purposes: Pacemaker and Cardioverter-Defibrillator Implantation.

Although ultrasound-guided axillary vein access (USGAVA) has proven to be a highly effective and safe method for cardiac electronic implantable device (CIED) lead placement, the collapsibility of the axillary vein (AV) during tidal breathing can lead to narrowing or complete collapse, posing a challenge for successful vein puncture and cannulation. We investigated the potential of the Valsalva maneuver (Vm) as a facilitating technique for USGAVA in this context. Out of 148 patients undergoing CIED implantation via USGAVA, 41 were asked to perform the Vm, because they were considered unsuitable for venipuncture due to a narrower AV diameter, as assessed by ultrasound (2.7 ± 1.7 mm vs. 9.1 ± 3.3 mm, p < 0.0001). Among them, 37 patients were able to perform the Vm correctly. Overall, the Vm resulted in an average increase in the AV diameter of 4.9 ± 3.4 mm (p < 0.001). USGAVA performed during the Vm was successful in 30 patients (81%), and no Vm-related complications were observed during the 30-day follow-up. In patients with unsuccessful USGAVA, the Vm resulted in a notably smaller increase in AV diameter (0.5 ± 0.3 mm vs. 6.0 ± 2.8 mm, p < 0.0001) compared to patients who achieved successful USGAVA, while performing the Vm. Therefore, the Vm is a feasible maneuver to enhance AV diameter and the success rate of USGAVA in most patients undergoing CIED implantation while maintaining safety.

Intra-pocket ultrasound-guided axillary vein puncture vs. cephalic vein cutdown for cardiac electronic device implantation: the ACCESS trial.

Intra-pocket ultrasound-guided axillary vein puncture (IPUS-AVP) for venous access in implantation of transvenous cardiac implantable electronic devices (CIED) is uncommon due to the lack of clinical evidence supporting this technique. This study investigated the efficacy and early complications of IPUS-AVP compared to the standard method using cephalic vein cutdown (CVC) for CIED implantation. ACCESS was an investigator-led, interventional, randomized (1:1 ratio), monocentric, controlled superiority trial. A total of 200 patients undergoing CIED implantation were randomized to IPUS-AVP (n = 101) or CVC (n = 99) as a first assigned route. The primary endpoint was the success rate of insertion of all leads using the first assigned venous access technique. The secondary endpoints were time to venous access, total procedure duration, fluoroscopy time, X-ray exposure, and complications. Complications were monitored during a follow-up period of three months after procedure. IPUS-AVP was significantly superior to CVC for the primary endpoint with 100 (99.0%) vs. 86 (86.9%) procedural successes (P = .001). Cephalic vein cutdown followed by subclavian vein puncture was successful in a total of 95 (96.0%) patients, P = .21 vs. IPUS-AVP. All secondary endpoints were also significantly improved in the IPUS-AVP group with reduction in time to venous access [3.4 vs. 10.6 min, geometric mean ratio (GMR) 0.32 (95% confidence interval, CI, 0.28-0.36), P < .001], total procedure duration [33.8 vs. 46.9 min, GMR 0.72 (95% CI 0.67-0.78), P < .001], fluoroscopy time [2.4 vs. 3.3 min, GMR 0.74 (95% CI 0.63-0.86), P < .001], and X-ray exposure [1083 vs. 1423 mGy.cm², GMR 0.76 (95% CI 0.62-0.93), P = .009]. There was no significant difference in complication rates between groups (P = .68). IPUS-AVP is superior to CVC in terms of success rate, time to venous access, procedure duration, and radiation exposure. Complication rates were similar between the two groups. Intra-pocket ultrasound-guided axillary vein puncture should be a recommended venous access technique for CIED implantation.

Axillary vein puncture versus cephalic vein cutdown for cardiac implantable electronic device implantation: a meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cephalic vein cutdown (CVC) and axillary vein puncture (AVP) are both recommended for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to September 5th, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary endpoint was acute procedural success. The effect size was estimated using a random-effect model as Risk Ratio (RR) and relative 95% Confidence Interval (CI). Results Overall, 8 studies were included, which enrolled 1926 patients and 3532 transvenous lead implants [66.3% (n=1277) males with an average age of 72.3±14.8 years]. Compared to CVC, AVP showed a significant increase in the primary endpoint (95.7 % vs 76.1 %; RR: 1.24; 95% CI: 1.09-1.40; p=0.001) (Figure 1). Total procedural time (Mean Difference [MD]: -8.25 min; 95%CI: -10.23- -6.27; p&amp;lt;0.0001; I2 =0%) and venous access time (MD: -6.24 min; 95%CI: -7.01- -5.47; p&amp;lt;0.0001; I2 =0%) were significantly shorter with AVP compared to CVC. No differences were found between AVP and CVC for incidence of pneumothorax (RR: 0.72; 95% CI: 0.13 - 4.0; p=0.71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p=0.26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15- 2.23; p=0.43), device infection (RR: 0.95; 95% CI: 0.14- 6.60; p=0.96) and fluoroscopy time (MD: -0.24 min; 95%CI: -0.75- 0.28; p=0.36). Conclusion Our meta-analysis suggests that AVP may improve procedural success and reduce total procedural time and venous access time compared to CVC.

Reducing radiation exposure and incision time in pacemakers implantation procedures using direct percutaneous axillary vein puncture

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Radiation exposure during device implantation depends overall on the operator experience but also on the type of venous access, type of device and number of leads implanted. Purpose to investigate radiation exposure/incision time for uni/bicameral pacemakers (PM) implantation procedures using direct percutaneous axillary vein puncture without primary fluoroscopy guidance and to assess the safety and the efficiency of this procedure strategy. Methods single center retrospective cohort study of patients implanted with unicameral and bicameral PM between January 2020 and December 2020 using direct percutaneous axillary vein puncture. All pts were given detailed explanations and informed consent. Procedural steps were: (I) direct percutaneous axillary vein puncture (anatomical landmarks: 1 or 2 cm medial and parallel to the deltopectoral groove at the level of the coracoid process); obtain separate vein access: 1 or 2 punctures; (II) skin incision and subcutaneous pocket dissection; (III) right ventricle (RV) ± right atrium (RA) lead placement and fixation. We analyzed the following data: fluoroscopy/incision time, dose area product (DAP) and the outcome related to procedure difficulties and complications. Results We collected data from 209 consecutive implant procedures; 152 patients (pts) underwent bicameral PM implantation, 57 pts received a unicameral device. All the procedures were done by the same operator (54 yo, 22 years of experience in PM implantation) using axillary access alone (2 years' experience in this technique). In 37 patients (18%) fluoroscopy guided puncture was needed. The mean fluoroscopy time was: bicameral PM 1.2±1.0 min (average incision time: 8.4±5.2 min); unicameral PM 0.4±0.3 min (average incision time: 6.5±4.3 min). The mean DAP was: bicameral PM 0.00358±0.00545 mGy/cm2; unicameral PM 0.00285±0.00449 mGy/cm2. In short term follow-up 1 patient (0.4%) developed pneumothorax and subsequent drainage was needed. Total follow-up period 19.7±4.3 months: at 6 months follow-up 1 patient (0.4%) presented lead fracture; 1 patient with DDD PM (0.4%) presented pocket infection; leads extraction were successful performed and another device was implanted. No other complications were noted. Conclusion Single venous access using axillary vein puncture was associated with reduced radiation exposure and decreased incision time. Our data showed a low incidence of complications.

Ultrasound-guided Axillary Vein Puncture for Cardiac Device Implantation: A Safe and Effective Approach

Ultrasound-guided axillary vein access is an effective alternative to conventional subclavian and cephalic access for cardiac implantable electronic device implantation. The aim of this study was to compare the safety, efficacy, and radiation exposure data of the ultrasound-guided axillary approach with other conventional access techniques. The study population included 130 consecutive patients, stratified as 65 (64% male; median age, 79 years) in the study group and 65 (66% male; median age, 81 years) in the control group. We performed a retrospective not-randomized analysis by comparing ultrasound-guided axillary vein puncture with subclavian and cephalic approaches in order to test the effect on X-ray exposure, total procedure time, and complications. Significant differences were observed in terms of radiation exposure, including fluoroscopy time (median, 95 s [study group] vs. 193 s [control group]; P < .001), air kerma (median, 29 mGy [study group] vs. 55.7 mGy [control group]; P < .001), and dose-area product (median, 8219 mGy·cm2 [study group] vs. 16736 mGy·cm2 [control group]; P < .001). The median procedure time was 45 min in the study group but 50 min in the control group (P < .05). Complications occurred in 6 control group patients (1 urticaria contrast medium-related, 3 pneumothorax, 2 subclavian artery puncture) and 2 study group patients (2 axillary artery puncture). We conclude that the ultrasound-guided axillary venous approach is a fast, feasible, and safe technique for cardiac lead implantation. It allows a significant reduction in fluoroscopy time without prolonging the procedural time. This approach offers direct visualization of the vessel during the puncture, so it can be useful in patients who cannot receive contrast medium, those who require "difficult" thoracic approaches (emphysema, too much or too little fat tissue), or those on anticoagulant therapy.

1074 AXILLARY VEIN PUNCTURE VERSUS CEPHALIC VEIN CUTDOWN FOR CARDIAC IMPLANTABLE ELECTRONIC DEVICE IMPLANTATION: A METANALYSIS

Abstract Introduction Transvenous lead implantation for pacemaker implantation is commonly performed by the cephalic vein cutdown (CVC), subclavian (SVP), or axillary vein puncture (AVP)(1). However, the CVC or AVP should be considered as first choice, according to the last guidelines, due to high rate of lead complications and pneumothorax of SVP. Objective To compare efficacy and safety of AVP compared with CVC for CIED implantation by a meta-analysis. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to September 5th, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary outcome was acute procedural success. The secondary outcomes were pneumothorax, lead failure, pocket hematoma/bleeding, device infection, total procedure time, venous access time and fluoroscopy time. The effect size was estimated using a random-effect model as Risk Ratio (RR) and relative 95% Confidence Interval (CI). Results A total of 8 studies were included enrolling 1926 patients with 3532 leads and average age of 72.3±14.8 years. AVP compared to CVC showed a significant increase in the procedural success (95.7% vs 76.1%; RR: 1.24; 95% CI: 1.09-1.40; p=0.001), (Figure 1). Total procedural time (Mean Difference [MD]: -8.25 min; 95%CI: -10.23- -6.27; p&amp;lt;0.0001) and Venous access time (MD: -6.24 min; 95%CI: -7.01- -5.47; p&amp;lt;0.0001) were significantly shorter with AVP compared with CVC. No differences were found between AVP and CVC for pneumothorax (RR: 0.72; 95% CI: 0.13 - 4.0; p=0.71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p=0.26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15- 2.23; p=0.43), device infection (RR: 0.95; 95% CI: 0.14- 6.60; p=0.96) and fluoroscopy time (MD: -0.24 min; 95%CI: -0.75- 0.28; p=0.36). Conclusion Our meta-analysis proved that AVP improves procedural success and reduces total procedural time and venous access time compared to CVC. Figure 1 – Forest plots comparing Acute Procedural Success between Axillary Vein Puncture Versus Cephalic Vein Cutdown.

A simple method of axillary venipuncture using single landmark for pacemaker leads implantation

Background Axillary venipuncture for pacemaker lead implantation has been demonstrated to be an effective method without fatal complications encountered with standard subclavian access approach, but the relatively high complexity limits its clinical practicability. Objective We are proposing a simple technique for axillary venipuncture using single point on clavicle as anatomical landmark with the possibility of alternative fluoroscopic assisted puncture as a backup. Methods Connecting point of medial to middle third of clavicle is located as the landmark. Deflected lateral 45°from sagittal line, an 18-guage needle tip is laid on the point and tangential to upper border of clavicle. Penetrated from the hub site, the needle is directed to the landmark at approximately 30–45° relative to body surface for venipuncture. If blind puncture failed, an alternative fluoroscopic method is performed. Upon successful venipuncture, a guide wire is positioned in inferior vena cava and a skin incision and subcutaneous pocket is made at the puncture site. Results Axillary vein puncture was successful for 106 of 113 patients (93.8%) in the study with mean access time of 3.6 ± 1.4 min. In 84 patients (74.3%), the vein was cannulated by blind puncture, and fluoroscopy guided method was required in other 22 patients (19.5%). The puncture of axillary artery occurred in one patient (0.09%) and no haemorrhage was observed after local pressure. No pneumothorax, hemothorax, or brachial plexus injury was found. Conclusions The approach of axillary vein puncture using single landmark on the clavicle is simple, effective and safe for pacemaker lead implantation.

A new method for localizing the landmark of axillary vein and its application

BackgroundAxillary vein puncture is a popular puncture site for pacemaker implantation. However, due to the lacking of body surface markers, the current puncture method is too complicated and affect the popularization and application of axillary vein puncture. Here, we performed a new body surface landmark to make the blind axillary vein puncture simple and easy. MethodsThe study population included 30 patients referred for pacemaker implantation using axillary vein puncture. Digital subtraction angiography (DSA) was used to determine the direction and the surface landmarks of the axillary vein. Medial cusp of thoracic triangle and the coracoid process were directly touched with fingers. The puncture point was about 1 cm below the coracoid, and the needle tip pointed to the medial cusp of thoracic triangle with the angle of 30–60°. ResultsThere was little variation in distribution of axillary vein. The body surface landmark of the junction of the axillary vein and the subclavian vein is on the medial cusp of thoracic triangle. In these 30 patients, blind axillary vein puncture was successful obtained in all patients. There was no pneumothorax and inadvertent arterial puncture. The pacemaker lead wire was placed smoothly. Moreover, the pacemaker pocket was ideally positioned when cut along the puncture point. ConclusionsBlind axillary vein access using the body surface landmark of the thoracic triangle is an effective method for pacemaker implantation and can obvious avoid the complications usually observed with the traditional subclavian vein approach.

Long-term incidence of cardiac device complications with intrathoracic versus extrathoracic venous access: results from the PLACE (Planning Lead Access for Cardiac Electrostimulation) study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Optimal venous access is crucial in successful cardiac device implantation. Most commonly used accesses are subclavian or axillary vein puncture and cephalic vein cutdown. The extrathoracic access has the advantage of reducing the risk of pneumothorax and lead disfunction; thus, this approach is recommended as the first choice approach. Purpose The aim of our retrospective registry was to evaluate the incidence of long-term device complications (pneumothorax, lead rupture or displacement, hematoma, infection or bleeding) with different venous approaches in four high-volume centers in Italy. Methods We collected data from implantation and device complications during follow up using available electronic records from each center. Results We included 4443 patients, mean age 73±11 years. Median follow up was 118 months (IC range 59-198 months). The incidence of any complication was 7.7 %, without difference between intrathoracic and extrathoracic access (7.8% vs 7.7% respectively, p=0.70). However, lead rupture was more frequent in the intrathoracic group (5.3% vs 1.4%, p=0.04). Conclusion In experienced, high-volume centers, the use of intrathoracic vein puncture in the case of unsuitable extrathoracic access may represent a safe alternative of venous access in patients undergoing cardiac device implantation, although associated with a higher occurrence of lead rupture.

Different venous approaches for implantation of cardiac electronic devices. A network meta-analysis.

Many of the complications arising from cardiac device implantation are associated to the venous access used for lead placement. Previous analyses reported that cephalic vein cutdown (CVC) is safer but less effective than subclavian vein puncture (SVP). However, comparisons between these techniques and axillary vein puncture (AVP) - guided either by ultrasound or fluoroscopy - are lacking. Thus, we aimed to compare safety and efficacy of these approaches. We searched for articles assessing at least two different approaches regarding the incidence of pneumothorax and/or lead failure (LF). When available, bleeding and infectious complications as well as procedural success were analyzed. A frequentist random effects network meta-analysis model was adopted. Thirty-six studies were analyzed. Most articles assessed SVP versus CVC. Compared to SVP, both CVC and AVP were associated with reduced odds of pneumothorax (OR: 0.193, 95%CI: 0.136-0.275 and OR: 0.128, 95%CI: 0.050-0.329; respectively) and LF (OR: 0.63, 95%CI: 0.406-0.976 and OR: 0.425, 95%CI: 0.286-0.632; respectively). No significant differences between AVP and CVC were demonstrated. Limited data suggests no major impact of different approaches on infectious and bleeding complications. Initial CVC approach required significantly more often an alternate/additional venous access for lead placement, compared to both AVP and SVP. No differences between these two were identified. Both AVP and CVC seem to decrease incident pneumothorax and LF, compared to SVP. Initial AVP approach seems to decrease the need of alternate venous access, compared to CVC. These results suggest that AVP should be further clinically tested.

P32 SELF–LEARN IMPLEMENTATION OF ULTRASOUND FOR THE STUDY AND ULTRASOUND–GUIDED PUNCTURE OF VASCULAR ACCESSES IN THE IMPLANTATION OF PACEMAKERS AND IMPLANTABLE DEFIBRILLATORS

Abstract Background The vascular access represents a crucial phase in the management of complications related to the implantation of devices. After the use of the axillary vein, which allows the elimination of intrathoracic complications as well as the subclavian crush of the catheters, the ultrasound–guided approach could represent the next step for the reduction of vascular complications. Experience All implants performed (n = 86) by an independent operator who implemented ultrasound to minimize complications related to central access were reviewed. During the first phase, the ultrasound–guided approach involved the study of vascular accesses before the start of the implant. The assessment took place before the preparation of the sterile field, for the localization of the axillary approach and for the study of the anatomical variants. It was immediately followed by the use of skin marks. The use of markers made it possible to attempt surgical isolation of the cephalic vein as a first approach. In case of failure, or the need for multiple accesses, the transition to central access could be facilitated by the presence of skin markers. This approach have not significantly modified the probability of successful axillary vein puncture without the use of venography (75% vs 71%, p NS). In the last phase all implants were performed with ultrasound–guided puncture with sterile technique before skin incision (n = 26). The procedures involved dual chamber (61%), single chamber (19%), CRTD (11%), dual chamber ICD. Ultrasound showed all cases of hypoplastic cephalic vein (15%). In the first three months of implementation, the success rate was 71.4% with 1 self–healing case of apical pneumothorax. In the following months the success rate rapidly increased to 94.1% (p &amp;lt; 0.05) with no pneumo or hemothorax. The median time to effective puncture was 28 seconds (8–450sec) in the second phase. It was possible to isolate the cephalic vein in 40% of cases for two or three chamber implants. Conclusions The ultrasound study of the accesses performed before the incision allows to identify the anatomy and to define the course of the axillary vascular system and its relationships. When performed with a sterile approach, it allows direct ultrasound–guided puncture before the surgical incision, with a high success rate from the early stages of implementation.

Distal axillary vein puncture to eliminate risk of pneumothorax - A study

Distal axillary vein puncture to eliminate risk of pneumothorax - A study