Axillary vein access for permanent pacemaker and implantable cardioverter defibrillator implantation: Fluoroscopy compared to ultrasound

Abstract

Background Axillary vein access (AVA) using fluoroscopic landmarks is an effective and safe approach for cardiac implantable electronic devices (CIEDs) implantation. However, it may result in a higher radiation exposure. Ultrasound‐guided axillary access (USAA) is an effective alternative technique to conventional subclavian access for CIEDs implantation. Studies comparing USAA and AVA using fluoroscopic landmarks are lacking. The purpose of this study was to compare the safety, efficacy, and radiation exposure data of the USAA approach with the AVA using fluoroscopic landmarks. Methods The study population included 95 consecutive patients (61% male, median age 78 years [71‐85 years]) referred for CIEDs implantation using AVA with fluoroscopic landmark (n = 46) or USAA (n = 49). Baseline characteristics and radiation exposure data (Air‐Kerma [mGy], DAP [Gy‐cm2], fluoroscopy time [seconds], and X‐rays emission time [seconds]) were compared according to the technique used for the AVA. Results Axillary vein was successfully accessed in 45 of 49 (92%) patients using ultrasound and in 42 of 46 (91%) patients using fluoroscopic landmarks (P = 1.00). Air‐Kerma, DAP, fluoroscopy time, and X‐rays emission time were shorter for USAA group compared with AVA using fluoroscopic landmarks (11 mGy [8‐20] vs 37 mGy [24‐81], P < .00001; 3 Gy‐cm2 [2‐5] vs 10 Gy‐cm2 [6‐16], P < .00001; 97 seconds [62‐163] vs 271 seconds [185‐365], P < .00001; and 7 seconds [4‐10] vs 21 seconds [13‐39], P < .00001). There were no significant differences between the two groups in median implant procedure time (P = .55). We did not encounter any acute or long‐term complications in both groups. Conclusions Ultrasound‐guided axillary vein cannulation for CIEDs implantation is a feasible and safe alternative approach and offers a significant reduction in fluoroscopy times without increasing procedural time.

Ultrasound guided axillary vein access: An alternative approach to venous access for cardiac device implantation

“…Lin et al 22 had previously reported a trend towards reduced fluoroscopy with UGAVA versus traditional techniques while Squara et al 10 reported no difference in fluoroscopy time with UGAVA versus cephalic vein access 10 . Additionally, Migliore et al 23 also reported reduced reduction in fluoroscopy time in patients undergoing UGAVA compared to fluoroscopic landmarks. While UGAVA can be done without fluoroscopy, our operators would routinely confirm wire presence within the inferior vena cava or the right ventricle as confirmation of venous rather than arterial access.…”

A Sound Method for Axillary Vein Access

“…This study otherwise adds to prior observational data suggesting that when compared to fluoroscopy-based axillary/subclavian vein access techniques, US guidance is safe and successful in >90% of patients with a trend towards reduced fluoroscopy use and no impact on total implant time [8][9][10].…”

“…A significant limitation to note in the current study and several others [8][9][10][11][12] is the reliance on data gathered from one or two operators with experience in ultrasound-guided axillary vein access. It does not account for the learning curve, which would be encountered by new adopters.…”

A sound method for axillary vein access

“…This study otherwise adds to prior observational data suggesting that when compared to fluoroscopy‐based axillary or subclavian vein access techniques, US guidance is safe and successful in greater than 90% of patients with a trend towards reduced fluoroscopy use and no impact on total implant time 8–10 …”

“…A significant limitation to note in the current study and several others 8–12 is the reliance on data gathered from one or two operators with experience in ultrasound‐guided axillary vein access. This does not account for the learning curve, which would be encountered by new adopters.…”