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BackgroundThe venous access for the insertion of permanent leads of cardiac implantable electronic devices is often achieved by venous cutdown of the cephalic vein, or by “blind” puncture of the subclavian vein using anatomical landmarks, or by fluoroscopy‐assisted methods.MethodsWe have retrospectively analyzed our clinical experience to verify the feasibility, the safety, and efficacy of the adoption of ultrasound‐guided puncture/cannulation of the axillary vein for this purpose.ResultsNine hundred eighty‐seven leads were placed during 548 consecutive procedures, accessing the axillary vein in the infraclavicular area using real‐time ultrasound guidance. Venipuncture was successful in 99.8% of cases. The access time was 11 seconds (range 4‐580). We recorded three cases of pneumothorax (0.5%), but no hemothorax and no hemo‐mediastinum. The incidence of local hematoma was 2.1% (12 cases). No injury to the brachial plexus or to the phrenic nerve was recorded. In a follow‐up of 33 months (range 16‐39), we observed no cases of “subclavian crush syndrome” (damage of the leads at the level of the thoracic inlet), and the rate of pocket infection/infective endocarditis was 0.7%.ConclusionIn our experience, ultrasound‐guided puncture/cannulation of the axillary vein for implantation of permanent leads is feasible, effective, and safe. It might be considered as a first option for this procedure.

The membranes of left atrial appendage (LAA) cavity are very rare entity. To date, only five cases of a membrane involving LAA have been described. In this report, we describe two different cases: in Case 1, we show image of a "real" nonobstructive membrane within the body of LAA, but in Case 2 we show a linear image, mimicking a membrane within the body of LAA. It really is a "pitfall" of transesophageal echocardiography (TEE).

We describe a case of an incidental finding of diverticulum in a patient presented to the Emergency Department for atypical chest pain, and we analyze the challenging differential diagnosis with aneurysm, pseudoaneurysm, and ventricular cleft.