Standardised procedure for pacemaker axillary vein puncture.

BACKGROUND

The axillary vein approach has emerged as a promising alternative to subclavian venous access for pacemaker implantation, offering potential advantages including reduced infection risk and enhanced procedural success. However, standardized protocols for fluoroscopy-guided axillary vein puncture remain undefined.

OBJECTIVES

This study aimed to (1) evaluate the feasibility of a simplified fluoroscopic technique for axillary vein puncture and (2) establish anatomical and clinical predictors of procedural success.

METHODS

In this retrospective cohort study, 178 consecutive patients undergoing pacemaker implantation at Shanghai Tongji Hospital (January 2022-December 2023) were stratified by puncture technique: right anterior oblique (RAO) 30°, Caudal 35° (C-arm angled toward feet), and vein-guided fluoroscopy. Demographics (age, sex), comorbidities (chronic obstructive pulmonary disease (COPD), spinal disorders), smoking status, and radiographic parameters (subclavian fat thickness, clavicle-first rib angle) were analyzed.

RESULTS

Axillary vein puncture was successful in 169/178 patients (94.9%) without venography. First-attempt success rates were 75.8% (135/178) for RAO 30° and 79.1% (34/43) for Caudal 35°. Key predictors of success included: Sex-specific anatomy, BMI threshold and Clavicular angx les. There was a significant difference in smoking status, subclavian fat thickness 2 cm below the collarbone between males and females (P < 0.001).ROC analysis identified BMI ≥ 23.84 kg/m² as optimal for success (AUC = 0.64, 95% CI: 0.48-0.83).Frontal clavicle-first rib angle independently predicted RAO 30° success (P = 0.012, OR = 1.08, 95% CI: 1.02-1.15), while RAO clavicle-first rib angle correlated with Caudal 35° success (P = 0.031, OR = 1.05, 95% CI: 1.01-1.09). In this study, the cumulative incidence of procedure-related complications was 1.69%. Severe complications such as pneumothorax or lead dislodgement were not observed, highlighting the safety profile of the intervention.

CONCLUSIONS

Successful fluoroscopy-guided axillary vein puncture depends critically on patient-specific anatomical factors, including sex, BMI, clavicle-first rib spatial relationships, and smoking status. Our standardized protocol achieved high success rates (94.9%) without ultrasound assistance, highlighting its utility in resource-limited settings.