Ultrasound-Guided Axillary Vein Puncture Versus Landmark-Guided Approach for Cardiac Implantable Electronic Device Placement.

Introduction: Ultrasound (US)-guided axillary vein puncture is a safe and effective approach for cardiac implantable electronic device (CIED) implantation, and it is highly recommended by the current consensus document. However, only reports on small populations are available in the current literature regarding the comparison of this technique with other traditional approaches (subclavian vein blind puncture and cephalic vein surgical cutdown).

Purpose: We aimed to assess the effectiveness and safety of US- guided axillary vein puncture using a microintroducer kit for CIED implantation as compared to the aforementioned traditional approaches.

Methods: All consecutive patients with an indication to CIED implantation were prospectively enrolled in our observational study from March 2021 to July 2023. Patients were divided into three groups based on venous access route, according to the operator's preference: cephalic vein surgical cutdown (G1), US-guided axillary vein puncture (G2), and subclavian vein blind puncture (G3). Clinical and procedural characteristics, success and complication rates were considered for analysis.

Results: A total of 1000 patients (65.2% male, mean age 75.5 ± 10.8 years) were enrolled. Cephalic vein surgical cutdown was chosen in 172 (G1, 17.2%), US-guided axillary access in 433 patients (G2, 43.3%), and subclavian vein in 395 (G3, 39.5%). Success rate was 77.6% in G1, 96.3% in G2, and 97.2% in G3 (G2 vs. G3, p = 0.5; G1 vs. G2, p < 0.0001; G1 vs. G2. vs. G3, p < 0.0001). Compared to subclavian and cephalic groups, in the US-guided axillary group, a successful access was obtained with a reduced mean number of puncture attempts (G2 vs. G3: 1.3 ± 0.9 vs. 1.8 ± 1, p < 0.0001) and needed reduced times to get access (G2 vs. G3: 15 s [10-30 s] vs. 40 [20-65 s]; p < 0.0001, G1 vs. G2: 210 s [180-247 s] vs. 15 s [10-30 s]; p < 0.0001) and to reach the superior vena cava, without differences in total procedural times (72.9 ± 30.4 vs. 75.7 ± 34.8 min, p = 0.24). Bailout fluoroscopy times [1 (0-8) s vs. 20 (10-58) s, p < 0.0001] and usage of vein angiography (11.9% vs. 51.3%, p < 0.0001) were lower in G2 as compared to G3. Complication rate did not differ among the three study groups (early complications: 2.9% in G1, 2.5% in G2, and 2.5% in G3, p = 0.96; late complications: 2.9% in G1, 1.6% in G2, and 0.8% in G3, p = 0.15).

Conclusions: US-guided axillary vein puncture for CIED implantation using a microintroducer kit is a safe technique with a very high success rate. Compared to other traditional approaches, it allows to get access with a lower number of puncture attempts and with reduced times, without prolonging the total procedural time. Moreover, x-ray use and need for contrast medium are very rare in US-guided axillary approach. Hence, it should be considered the strategy of choice for most patients undergoing CIED implantation.