Ultrasound-guided transcutaneous axillary vein access for cardiac electronic device implantation, revision and upgrade: feasibility and procedural outcome

Julius Nikorowitsch (Hamburg)1, T. Üctas (Hamburg)1, K. Borof (Hamburg)1, A. Metzner (Hamburg)2, J. Wenzel (Hamburg)1, S. J. Winkelmann (Hamburg)2, S. Pecha (Hamburg)3, H. Reichenspurner (Hamburg)3, P. Kirchhof (Hamburg)1, T. Tönnis (Hamburg)2, N. Becher (Hamburg)1

1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 2Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie Hamburg, Deutschland; 3Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland


Background. Venous access is required to implant leads of cardiac implantable electronic devices (CIED). Traditionally, subclavian vein access is used to gain vascular access. The preferred cephalic vein access is frequently infeasible for CIED revisions or upgrades. Several reports suggest that fluoroscopy-guided puncture of the axillary vein is associated with lower long- and short-term thoracic complications. 

Aim. Here we report the procedural outcome of introducing ultrasound-guided, transcutaneous axillary vein access (axillary group) for first CIED implantation, revision or upgrade in a large tertiary care center. Outcomes were compared to implantations via the widely used, landmark-guided subclavian vein approach (subclavian group). 

Methods. Retrospective single-center, non-randomized analysis of consecutive patients undergoing implantation or upgrade of a CIED between January 2021 and August 2023. The axillary access was initially introduced by one operator. The choice of access was driven by the preference of the operator and partly evolved during observation period towards axillary access. For axillary access, the axillary vein was visualised by ultrasound at the deltopectoral groove (Figure 1A) followed by a transcutaneous ultrasound-guided puncture and wire insertion (Figure 1B and C). Thereafter, the skin was incised approximately 0.5cm mediocaudal from the wire insertion site parallel to the deltopectoral groove to create a device pocket (Figure 1D). The wire or wires were pulled through the skin from inside the pocket followed by sheath insertion and a standard procedure for lead implantation. Endpoints were defined as acute success rates of central venous access for the chosen approach and adverse events including pneumothorax with and without intervention, hemothorax and pocket hematoma applying an intention-to-treat analysis. The p-value tested the difference between the axillary and subclavian group.

Results. Overall, 986 patients (mean age 74, IQR 64-82 years, 35% women) underwent a new implantation, revision or upgrade of a CIED with a total of 1636 lead implants. Axillary access was used in 578 patients with a primary procedural success in 532 patients (92%). Success rates were higher in the subclavian group with 394/408 (97%) (p=0.003). Considering only device upgrades or revisions, axillary puncture was successful in 68/79 patients (86%), the subclavian access in 44/47 patients (94%) (p=0.193).  Overall, acute complications occurred in 2/578 patients in the axillary group (0.3%), and in 17/408 patients in the subclavian group (4.2%) (p<0.001): Two patients in the axillary group developed pneumothorax requiring intervention (0.3%). In the subclavian group, 12 patients (2.9%) developed pneumothorax with eight patients (2%) requiring intervention, three patients (0.7%) developed hemothorax, and two patients (0.5%) developed pocket hematoma. There were no further complications in the axillary group.

Conclusion. Introduction of transcutaneous, ultrasound-guided axillary access is feasible in a large training centre with very low acute complication rates compared to subclavian venous access both for new implantations and for revisions and upgrades. 

Figure 1: Axillary vein access via transcutaneous ultrasound-guided wire insertion. A Position of the ultrasound probe for in-line visualization of the axillary vein. Wire in the axillary vein visualized by ultrasound. Wire insertion site. D Site of skin insertion.

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