Predictors of successful ultrasound‐guided lead implantation

Abstract

Background Technical advances have improved the safety of cardiac implantable electronic device (CIED) insertion, but periprocedural complications persist. Despite ultrasound (US) guidance for vascular access being feasible and exhibiting shorter fluoroscopy times, it is not widely adopted for insertion of CIEDs. Thus, we studied the use of US for CIED insertion to (1) quantify the success rate of venous cannulation, (2) identify predictors of failed cannulation, and (3) quantify the rate of complications using US guidance. Methods We studied 166 consecutive patients who underwent US‐guided CIED implantation. Anatomic parameters of the axillary vein were measured. The primary outcome was success (group 1) or failure (group 2) to obtain vascular access utilizing US guidance. Secondary outcomes included pneumothorax and hematoma. Results Successful US‐guided cannulation occurred in 154 of 166 patients (93%). No patient had a pneumothorax. Hematoma occurred in 1 of 166 patients (0.01%). Group 2 exhibited higher male proportion at 11 of 12 (92%) compared with 94 of 154 (61%) in group 1 (P = .03), increased vein depth at 3.84 versus 2.85 cm (P = .003), more right‐sided implants (P = .03), higher weight at 104.6 versus 85.3 kg (P = .017), higher body mass index at 35.6 versus 29.2 kg/m2 (P = .049), and higher body surface area at 2.24 versus 1.99 m2 (P = .013). Other parameters were statistically nonsignificant. In multivariate analysis, vein depth remained significantly associated with failure. Conclusion Using US guidance for CIED implantation is successful in the vast majority (93%) of patients. Rare cases of unsuccessful cannulation were associated with right‐sided implants and increased venous depth.

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

“…A recent small randomized study demonstrated a 98% success rate with UGAVA versus 55% with cephalic venous cut‐down 14 . As with other studies assessing UGAVA, we found that patients with a higher BMI were more likely to have unsuccessful UGAVA 14,21 . Nevertheless, UGAVA was still successful in the majority of patients with BMI more than 30.…”

“…The reported 4% overall 30‐day complication rate is similar to the 3%–6% reported cardiac device complication rate 1–4,6 . Cardiac device implantation international registries and systematic reviews report complications frequencies of: pneumothorax 1.3%, hematoma 2.3%, infection 1.7%–3.5%, lead dislodgment in 1.8%–10.6% 1,6,20,25–27 . Comparatively, our study revealed a low complication frequency, especially given the broad definition of hematoma.…”

“…Blunt and electrosurgical dissection were then carried out to the pre‐pectoral fascia to create the pocket. If present, any remaining wire(s) were then pulled into the pocket from underneath so they were through the incision 1 . Thereafter, the implant procedure was completed in a conventional fashion.…”

“…Despite advancements in lead design and operator training/experience, the incidence of lead‐related complications with transvenous cardiac implantable electronic device (CIED) implantation varies between 3% and 6% 1–6 . A desire to avoid transvenous lead‐related complications has led to development of a leadless pacemaker and the subcutaneous implantable cardioverter‐defibrillator (ICD) 7–9 .…”

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

“…Ultrasound‐guided axillary vein puncture has proved to be effective and safe as reported by several studies both in pediatric and adult population 14‐17 . Recently, Ahmed et al reported that ultrasound‐guided CIED implantation is successful in the vast majority (93%) of patients, and rare cases of unsuccessful cannulation were associated with right sided implants and increased venous depth 19 …”