Bhuva Anish N, Zaw Hnin, Graham Adam, Muthumala Amal, Moore Philip, Dhinoja Mehul
Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.
Institute of Cardiovascular Sciences, University College London, London, UK.
Pacing Clin Electrophysiol. 2025 Sep;48(9):967-972. doi: 10.1111/pace.70021. Epub 2025 Jul 31.
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.
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).
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.
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.
在心脏设备植入中，超声（US）引导下的腋静脉穿刺置管的学习曲线在现实世界中的经验有限，且通常在皮肤切口前进行。我们研究了在标准工作流程中US引导下静脉穿刺置管的学习曲线、辐射暴露、安全性和有效性。
由一位经验丰富的电生理学家进行US引导下的穿刺置管，其此前未应用过该技术，使用标准血管超声探头并对工作流程进行最小化修改。使用穿刺时间（针到导丝时间）评估学习曲线。记录直至出院的并发症情况，并将操作成功定义为有效性。根据穿刺时的透视时间估计辐射剂量节省情况，对照组采用传统透视下标志引导穿刺（44次穿刺）。
74例患者共进行了147次US引导下的穿刺，用于一根（8%）、两根（71%）或三根（17%）导线置入，或升级（4%）。穿刺成功率为97%（n = 72）。没有与穿刺相关的围手术期并发症。首次US引导下的穿刺时间为30秒（四分位数间距[IQR]：17,60），与透视引导下的穿刺时间相似（43秒，IQR：24,58；p = 0.45）。45次操作后穿刺时间趋于稳定，从首次的15次操作到最后15次操作，穿刺时间从81秒（IQR：61,90）降至16秒（IQR：10,20）（p < 0.001）。96%（n = 69）的操作不需要透视。4%（n = 3）在导丝通过困难后需要1秒透视来确认导丝位置。与对照组相比，估计节省的透视时间为30秒（IQR：15,78），累积皮肤剂量为0.4（IQR：0.26,1.7）mGy，相当于1.3（95%置信区间：0.26,1.45）次患者胸部X线片的辐射暴露。
在标准工作流程中，US引导下的心脏设备植入腋静脉穿刺置管是可行的，且可减少辐射暴露。学习曲线时间是可接受的，即使在培训期间该操作也是安全的。
