Elsevier

Heart Rhythm

Volume 19, Issue 7, July 2022, Pages 1184-1191
Heart Rhythm

Contemporary Review
How to perform extrathoracic venous access for cardiac implantable electronic device placement: Detailed description of techniques

https://doi.org/10.1016/j.hrthm.2022.02.020Get rights and content

Venous access is needed for implantation of cardiac implantable electronic devices (CIEDs) with endocardial leads. Extrathoracic venous access in the prepectoral region has become the standard of care for CIED implantation because of lower risks for pneumothorax and likely less lead malfunction due to subclavian crush syndrome. The most common extrathoracic venous access sites in the pectoral region are extrathoracic subclavian vein access, axillary vein access, and cephalic vein access. This review provides a detailed description of the anatomy, technical considerations, and relative advantages and disadvantages of each of these extrathoracic venous access sites.

Introduction

Implantation of cardiac implantable electronic devices (CIEDs) has been increasing over the last few decades worldwide and in the United States.1 Procedures for CIED placement with endocardial leads typically require 1 or more venous access sites to place the leads in the cardiac chambers or coronary sinus. Various veins have been used since the first pacemaker implantation with endocardial lead in 1959.2 The most commonly used veins in clinical practice for conventional CIED placement are located in the prepectoral area of the upper chest. These veins are the cephalic vein, axillary vein, and subclavian vein. Previously, intrathoracic subclavian venous puncture (ISVP) had been the traditional access site for CIED lead placement, but this approach has fallen out of favor because of its higher complication rate. In this review, we describe the different modalities of extrathoracic venous access techniques for CIED placement.

Section snippets

Anatomy of the thoracic outlet and subclavian, axillary, and cephalic veins

The thoracic outlet is the space in the lower neck as well as between the thorax and axilla. It is bounded by the clavicle, the first thoracic rib, the sternum, and the pectoralis minor muscle insertion onto the coracoid process of the humerus (Figure 1). The thoracic outlet is divided into 3 areas: the scalene triangle above the clavicle, the costoclavicular space between the clavicle and the first rib, and the subcoracoid space below the clavicle.3, 4 The subclavian artery, the subclavian

Axillary vein access and extrathoracic subclavian vein access

Both extrathoracic subclavian vein and axillary vein are outside of the chest and have a larger diameter than the cephalic vein. Therefore, extrathoracic subclavian vein access (ESVA) and axillary vein access (AVA) became preferential access strategies for CIED. ESVA uses a short portion of the subclavian vein, but its anatomic location and clinical outcome are similar to AVA. Independent of approach, ESVA/AVA has a very high success rate of >90% to 95%.7, 8, 9, 10, 11

CVA

CVA became the standard venous access strategy in the 1960s40 and is the preferred first access approach in 60% of the centers in Europe,41 in contrast to the United States where AVA/ESVA is preferred.

Complications of extrathoracic vein access

Pneumothorax is associated with prolonged hospital stay, significantly increased cost, and mortality.46 The major advantage of ESVA/AVA and CVA compared to conventional ISVP is a much lower rate of pneumothorax (0.19% in CVA vs 1.30% in ISVP; P <.001 in meta-analyses).17, 43, 44 CVA was associated with lower lead failure compared with ISVP (0.50% vs 1.92%; P <.0001).43, 45 ESVA/AVA have potentially less subclavian crush syndrome and lead malfunction than ISVP,38, 47, 48, 49 but more robust

Conclusion

Extrathoracic prepectoral vein access for conventional CIED has become the preferred technique because of its safety and efficacy, especially via the extrathoracic subclavian vein and the axillary vein. Venous access guided by fluoroscopy with or without venography or by US can be easily self-taught. CVA continues to be successfully used but has become less popular because fewer clinicians are trained in this technique and because of the relative simplicity and safety of access to the

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  • Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

    Disclosures: The authors have no conflicts of interest to disclose

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