Implementation of transcutaneous ultrasound-guided axillary vein access for implantations, revisions and upgrades of cardiac implantable electronic devices in a large tertiary care center.

BACKGROUND

Central venous access for cardiac implantable electronic device (CIED) implantations is conventionally acquired via the cephalic or subclavian vein. Controlled data suggest that axillary vein access may reduce complications.

OBJECTIVES

We, therefore, shifted institutional practice from subclavian vein access to ultrasound (US)-guided axillary vein access for new implantations and revisions or upgrades and report on implant success rates, learning curves and periprocedural complications.

METHODS

Between January 2021 and August 2023, all patients undergoing CIED implantations, revisions or upgrades were analyzed. US-guided axillary access was introduced starting with one operator and spreading to most operators and trainees thereafter. Periprocedural outcomes and complications (pocket hematoma, hemothorax, and pneumothorax) of transcutaneous US-guided axillary vein access were compared to the subclavian vein access.

RESULTS

In this study, 986 patients (median age: 75 years, interquartile range (IQR) 64-82 years, 35% women) with 87% new implantations and 13% revisions or upgrades were included. Transcutaneous US-guided axillary access was successful in 535/578 patients (93%), subclavian vein access in 400/408 patients (98%) (p < 0.001). For device upgrades or revisions specifically, axillary access was successful in 69/79 patients (87%), versus 45/47 patients (96%) with subclavian access (p = 0.208). The learning curve for axillary access was steep with success rates of 93 after 30 cases per operator. Complications occurred in 2/578 patients (0.3%) undergoing axillary vein access versus 17/408 patients (4.2%) (p < 0.001) undergoing subclavian vein access.

CONCLUSION

The implementation of transcutaneous US-guided axillary vein access for implantation, revisions and upgrades of cardiac electronic devices is feasible in a large tertiary care center. The periprocedural complications are rare.