Background:Combined ultrasound (US)-guided pectoral nerves (PECS) block and axillary vein (AV) puncture for cardiac implantable electronic devices can be effective to achieve optimal perioperative pain management and prevent access-related complications. Methods:A total of 36 patients who underwent combined US-guided PECS block and AV puncture were included. All routinely recorded parameters, including clinical and demographic characteristics, periprocedural medical administrations, the time taken for both PECS block and AV puncture, procedure time, postprocedural pain score, and procedure-related complications, were collected and analyzed. Results: In total, 54 leads were placed in 36 patients. The combined US-guided PECS block and AV puncture was performed successfully in 35 (97.2%) patients without the need for fluoroscopy or venography. AV access for each lead was achieved in a single attempt in 80.6% of cases. The time for both PECS block and AV puncture was 223.6 ± 52.1 s, including the time to apply incision site anesthesia. Additional sedatives and/or local anesthetics were required in two patients during procedure. Visual analog scale average of the patients in the 1st, 6th, and 24th h was 3.7 ± 1.14. 1.61 ± 1.29, and 0.08 ± 0.28, respectively. After the procedure, four patients (three of them woman) needed analgesics. There were no venous access-related complications. Conclusions: This new combined technique maintains both surgical and postoperative analgesia and prevents vascular access-related complications without significant increase on procedure time. K E Y W O R D S axillary vein, cardiac implantable electronic devices, pectoral nerve block, ultrasound, venous access 1 1026

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Objective: To determine the patency rates and reasons for failure using different access routes for tunneled hemodialysis catheters. Methods: The records of patients who underwent insertion of 14 French tunnelled hemodialysis catheters were retrospectively analyzed. Catheter patency survival was demonstrated using Kaplan-Meier survival curve. Catheter failure and exchange reasons were evaluated. Results: One hundred and six patients underwent 474 catheter exchanges (mean/patient 4.47±1.62). Access was via right internal jugular vein (IJV) n=40, left IJV n=23, right femoral vein (FV) n=18, left FV n=11 and transhepatic vein n=14. The causes of catheter failure and exchange were: catheter-associated infection, catheter thrombosis, fibrin sheath and catheter tip malposition. Mean primary and cumulative catheter patency time (721 and 1276 days, respectively) was higher in the right IJV group compared with the others (p<0.001). The same parameters were lowest in the transhepatic group, being 118 and 466 days, for primary and cumulative patency, respectively (p<0.001). The incidence of catheter-related infections was higher in the left FV (0.42/100 patient-days) and catheter tip malposition was higher in the transhepatic (0.38/100 patient-days) and in the left IJV (0.32/100 patient-days). Conclusion:The use of right IJV should be the first option for hemodialysis access route. Based on our findings, if right IJV is unavailable the optimal access routes in order would be left IJV, right FV, left FV and finally transhepatic vein.

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