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.