Ultrasound Guided Venous Access for Cardiac Devices: Defining Learning Curve for Safety, Efficacy, and Radiation Exposure.

BACKGROUND

There is limited real-world experience of the learning curve for ultrasound (US) guided axillary venous access for cardiac device implantation, and it is usually performed before cutaneous incision. We investigated the learning curve, radiation exposure, safety, and efficacy of US-guided venous access in standard workflow.

METHODS

US-guided access was performed by an experienced electrophysiologist with no prior application of the technique by using a standard vascular US probe and minimal modification to workflow. The learning curve was evaluated using access time (needle-to-wire time). Complications were recorded until hospital discharge, and efficacy was defined by procedural success. Radiation dose savings were estimated based on fluoroscopy time for access, and a control group underwent conventional fluoroscopy landmark-guided access (n = 44 punctures).

RESULTS

147 US-guided punctures were performed in 74 patients for one (8%), two (71%), or three (17%) leads, or upgrades (4%). Access was successful in 97% (n = 72). There were no access-related peri-procedural complications. First US-guided access time was 30 seconds (interquartile range [IQR]: 17,60), and was similar to fluoroscopy-guided access time (43 seconds, IQR: 24,58; p = 0.45). Access time stabilized after 45 procedures, decreasing from 81 (IQR: 61,90) to 16 seconds (IQR: 10,20) from the first to the last 15 procedures (p < 0.001). 96% (n = 69) did not require fluoroscopy. 4% (n = 3) required 1 second fluoroscopy to confirm wire position after difficult passage. Estimated radiation exposure saving from controls was 30 seconds (IQR: 15,78) of fluoroscopy, resulting in 0.4 (IQR: 0.26,1.7) mGy cumulative skin dose, equivalent to 1.3 (95% confidence interval: 0.26,1.45) patient chest radiograph radiation exposure.

CONCLUSION

US-guided axillary venous access for cardiac device implantation is feasible in a standard workflow and reduces radiation exposure. The learning curve time is acceptable, and the procedure is safe, even during training.