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

Abstract

Objectives 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. Methods 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. Results 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. Conclusion 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.

Safety and Efficiency of Cephalic Vein Puncture by Modified Seldinger Technique Compared to Subclavian Vein Puncture for Cardiac Implantable Electronic Devices

“…In terms of complications, the superiority of the cephalic over subclavian vein access has been extensively proven [ 3 , 6 , 8 ]. Consistent with this data, pneumothorax only occurred in the subclavian access group in our cohort.…”

“…Therefore, CVC access is not successful in all cases with a need to switch to an alternative, usually subclavian venous access [ 6 , 7 , 8 ]. Depending on the surgeons experience, this was required in 10%–40% of the patients with primarily cephalic approach [ 5 , 7 , 9 ].…”