Prospective Study of Axillary Vein Puncture with or Without Contrast Venography for Pacemaker and Debrillator Lead Implantation

HARAN BURRI, HENRI SUNTHORN, PIERRE-ANDRE DORSAZ, and DIPEN SHAH

From the Cardiology Service, University Hospitals of Geneva, Geneva, Switzerland

BURRI, H., ET AL.: Prospective Study of Axillary Vein Puncture with or Without Contrast Venography for Pacemaker and Debrillator Lead Implantation. Axillary vein puncture may be used to implant pacemaker (PM) or cardioverter debrillator leads, though usually requires venography. We prospectively compared punctures guided by venography versus a new radiological landmark. In 232 patients, the puncture was guided by injecting diluted contrast material via an ipsilateral peripheral vein (group A, n = 142), or without venography using the intersection of the lateral borders of the second and third rib as a radiological landmark, followed by contrast injection in case of failure (group B, n = 90). We implantated 13 leads per patient. In group A, implantation was successful in 135 patients (95%) and in group B in 55 patients (61%, P < 0.001 vs group A). Subsequent contrast injection allowed successful implantations in 34 of 35 patients, with an success rate of 97% for the overall study population of 224 patients. Venous access was achieved after a mean of 10.4 3.2 minutes of skin incision in group A versus 9.4 3.0 minutes in group B (ns). Pneumothorax occurred in two patients (1% overall). Thus non-contrast guided puncture using a new radiological landmark was successful in a majority of patients. This technique may be useful in absence of ipsilateral peripheral vein access, or presence of contrast allergy. (PACE 2005; 28:S280S283) cardiac pacing, implantable cardioverter debrillator, lead implantation, axillary vein puncture Introduction Pacemaker (PM) and implantable cardioverter debrillator (ICD) leads are usually implanted by subclavian puncture or via cephalic venous cut down. The former technique carries a risk of pneumothorax and may result in lead damage due to subclavian crush, whereas the latter is highly dependent on venous anatomy and may be time consuming. The axillary vein was rst used for placing PMs leads over 20 years ago,1 but has become increasingly popular only over the last few years, after the introduction of axillary vein puncture techniques, which are rapid, widely applicable, and may be associated with less lead dysfunction.2 However, since some patients may not have an ipsilateral peripheral venous access, or may be allergic to contrast agents, alternative techniques to access the axillary vein are desirable. Our aim was to prospectively compare axillary vein punctures with and without contrast venography, using a new uoroscopic landmark. Patient Population and Methods Consecutive patients referred for PM or ICD implantation were prospectively evaluated using axillary vein puncture as the primary technique. Contrast-guided axillary vein puncture was initially used in all patients. However, after review of the venograms obtained in the rst 30 patients, we identied a new radiological landmark described below, which was subsequently tested. The study population was thus divided into two groups. Patients in group A had initial contrastguided axillary vein punctures. In group B, we attempted punctures using the new radiological landmark without venography, followed by the contrast-guided approach in case of unsuccessful implantation.
Contrast-guided Axillary Vein Puncture

A total of 10 cc of contrast dye diluted 1:1 with normal saline to reduce viscosity and facilitate the bolus injection was injected via an ipsilateral peripheral vein and ushed with 20 cc of saline. The opacied axillary vein was then punctured under uoroscopy, at the border or medial to the rib cage margin (Fig. 1), with repeated boluses of semi-diluted contrast material if needed. In case of unsuccessful puncture, a cephalic venous cut down or a subclavian puncture were performed.
Axillary Vein Puncture without Venography

Address for reprints: Haran Burri, M.D., Cardiology service, University Hospital, 23, Micheli-du-Crest, 1211 Geneva, Switzerland. Fax: 0041 22 372 72 29; e-mail: haran.burri@hcuge.ch

Review of venographies performed in an antero-posterior projection during device implantation indicated that the axillary vein usually courses at the level of, or slightly cephalad to, the intersection of the inferior border of the second rib and the superior border of the third rib at the
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Figure 1. Contrast-guided axillary vein puncture. Note that the axillary vein lies just cephalad to the intersection of the inferior border of the second rib and the superior border of the third rib at the rib cage margin (arrow).

If venous access was not obtained within approximately 15 seconds, contrast agent was injected to guide the puncture as previously described, to minimize the risk of complications. All procedures were performed by two experienced physicians. Skin incisions were made parallel to the axis of the clavicle (HS) or along the delto-pectoral groove (HB). In case of implantation of multiple leads, the guidewire from the rst puncture was used to orient subsequent sticks. The devices were implanted on the left side in all but four patients. Duration from skin incision to successful introduction of a guide wire from the axillary vein to the superior vena cava, including the time needed for to create the pocket, was recorded, as well as the volume and number of contrast injections. All procedure-related complications were noted, with routine chest roentgenograms performed to detect the development of pneumothorax. Patients were examined on the following day and at 2 months after the procedure. Statistical Analysis Unpaired Students t-test was used to compare continuous variables between the two groups. Fishers exact test was used to compare implantation success and complication rates. A P value <0.05 was considered statistically signicant. Values are expressed as means SD. Results The study included 232 patients (mean age = 75 11 years, 147 men) in whom a total of 371 PM and 27 ICD leads were implanted (13 leads/patient). Efcacy of axillary vein puncture in the two groups is shown in Figure 3. In group B, venous access using the radiological landmark only was successful in 55 patients (61% P < 0.001 vs group A), with subsequent venography resulting in a successful axillary venous puncture in

rib cage margin (Fig. 2). We used this uoroscopic landmark to position the puncture site on the pectoral muscle with the needle pointing toward the head of the patient at a 60 angle to the skin surface. The needle was then advanced until blood was aspirated, care being taken to not cross the rst rib (which results in subclavian vein puncture).

Figure 2. Axillary vein puncture using the radiological landmark without venography (the needle was introduced at the level of the arrow and advanced until the vein was punctured).

Figure 3. Results of axillary vein puncture in the two study groups.

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all but one patient. The overall success rate was similar both groups. Axillary vein puncture was ultimately successful in 224 patients (97% of the study population), with successful lead implantations using cephalic or subclavian access in all remaining patients. The incision to guidewire times were 10.6 3.3 minutes in group A, and 9.3 2.7 minutes in group B (ns). Venography required 1.1 0.5 contrast injections per patient, representing a mean of 7.2 3.7 cc of contrast material. Procedure-Related Complications Pneumothorax occurred in two patients in group B (1%) both of whom required a chest tube. There was no hemothorax. Accidental puncture of the axillary artery occurred in ve patients group A and four patients in group B (ns), which were uncomplicated. There was no evidence of plexus nervous lesions, and no patient developed a clinically signicant hematoma. Reinterventions for lead repositioning were needed in three patients, one of whom developed a device infection requiring PM explantation. Discussion Our study of axillary vein puncture, the largest series published to date, indicates that this technique is safe and allows rapid venous access in nearly all patients. Both approaches studied were similarly effective. Though the complication rates were low in both groups, pneumothorax occurred in two patients in group B. The success rate using our landmark would have probably been higher, had we withheld contrast injection when venous access was not immediately obtained. This technique may be used as an initial attempt before venography, or as an alternative in patients with contrast allergy or without ipsilateral peripheral venous access. Other authors have explored landmarks for extra-thoracic venous access for lead implantation. Byrd rst described a technique for cannulating the extra-thoracic subclavian vein as it crosses the rst rib, before becoming the axillary vein after crossing the inferior rib border.3,4 The technique requires maneuvering of the needle from the clavicle to the rst rib by a series of partial withdrawals and reinsertions under uoroscopy. Orientation is maintained by touching the rib with each maneuver, which may be considered risky by many operators and probably explains why this technique has not gained widespread acceptance. Another approach uses a Doppler probe to locate the extra-thoracic subclavian/axillary References
1. Garcia-Rinaldi RF. Insertion of the lead of a permanent transvenous pacemaker utilizing an axillary approach. A

vein, which was successful in all of 59 patients.5 However, this technique requires specialized equipment. Blind axillary venous access using the delto-pectoral groove as a surface landmark was successfully used by Belott in 165 of 168 patients.6 However, this high success rate was reported by a single experienced physician, and many are reluctant to use an unguided stick. Our technique using uoroscopic guidance would probably be more readily accepted. However, most physicians who currently perform axillary vein punctures use contrast venography. In 50 patients, Ramza et al. had a 100% success rate versus 75% when the axillary vein was approached medially versus 75% when approached laterally with respect to the rib cage margin.7 The same investigators randomly assigned 200 patients to contrast-guided extrathoracic subclavian puncture versus cephalic venous cut down, with success rates of 99% versus 64%, respectively. Extra-thoracic subclavian vein puncture was also signicantly more rapid, without excess complications. Whether the extrathoracic subclavian or the axillary vein should be targeted remains unsettled. However, variations in patient anatomy and depth of the veins complicate the prediction of the exact site of entry into the vein. It seems, therefore, preferable to chose an axillary vein puncture, advancing the needle to the level of the extra-thoracic subclavian vein, if necessary, without crossing the rst rib. Limitations of Our Study Our patients were not randomly assigned to the study groups since the landmark-guided approach was introduced secondarily. The potential underestimation of efcacy using the uoroscopic landmark has already been mentioned. Conclusions Contrast-guided axillary vein puncture is becoming increasingly popular, as it is safe, rapid, widely applicable, and has the potential of reducing the incidence of lead failure, though long-term observations are still pending. However, injections of contrast may be limited by contrast allergy or absence of ipsilateral venous access. Various other techniques for extra-thoracic venous canulation have previously been described, none of which have has gained widespread acceptance. Our simple radiological landmark-guided approach was effective in a majority of patients, and represents a helpful alternate technique when venography is not possible.

solution to the unsuitable cephalic vein. Chest 1978; 73: 561.

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2. Calkins H, Ramza BM, Brinker J, et al. Prospective randomized comparison of the safety and effectiveness of placement of endocardial pacemaker and debrillator leads using the extrathoracic subclavian vein guided by contrast venography versus the cephalic approach. Pacing Clin Electrophysiol 2001; 24:456464. 3. Byrd CL. Safe introducer technique for pacemaker lead implantation. Pacing Clin Electrophysiol 1992; 15:262267. 4. Byrd CL. Clinical experience with the extrathoracic introducer insertion technique. Pacing Clin Electrophysiol 1993; 16:17811784. 5. Fyke FE 3rd. Doppler guided extrathoracic introducer insertion. Pacing Clin Electrophysiol 1995; 18:1017 1021. 6. Belott PH. Blind axillar venous access. Pacing Clin Electrophysiol 1999; 22:10851089. 7. Ramza BM, Rosenthal L, Hui R, et al. Safety and effectiveness of placement of pacemaker and debrillator leads in the axillary vein guided by contrast venography. Am J Cardiol 1997; 80:892 896.

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