Axillary Vein Puncture Without Contrast Venography for Pacemaker and Defibrillator Leads Implantation

Caudal fluoroscopic guidance for the insertion of transvenous pacing leads

BACKGROUND

Pneumothorax is a well-recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion.

METHODS

Retrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography.

RESULTS

Three thousand two hundred fifty-two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16-102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01).

CONCLUSION

Caudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.

Feasibility of Ultrasound-Guided Axillary Vein Puncture under Valsalva Maneuver for Diagnostic and Cardiovascular Interventional Purposes: Pacemaker and Cardioverter-Defibrillator Implantation

Although ultrasound-guided axillary vein access (USGAVA) has proven to be a highly effective and safe method for cardiac electronic implantable device (CIED) lead placement, the collapsibility of the axillary vein (AV) during tidal breathing can lead to narrowing or complete collapse, posing a challenge for successful vein puncture and cannulation. We investigated the potential of the Valsalva maneuver (Vm) as a facilitating technique for USGAVA in this context. Out of 148 patients undergoing CIED implantation via USGAVA, 41 were asked to perform the Vm, because they were considered unsuitable for venipuncture due to a narrower AV diameter, as assessed by ultrasound (2.7 ± 1.7 mm vs. 9.1 ± 3.3 mm, p < 0.0001). Among them, 37 patients were able to perform the Vm correctly. Overall, the Vm resulted in an average increase in the AV diameter of 4.9 ± 3.4 mm (p < 0.001). USGAVA performed during the Vm was successful in 30 patients (81%), and no Vm-related complications were observed during the 30-day follow-up. In patients with unsuccessful USGAVA, the Vm resulted in a notably smaller increase in AV diameter (0.5 ± 0.3 mm vs. 6.0 ± 2.8 mm, p < 0.0001) compared to patients who achieved successful USGAVA, while performing the Vm. Therefore, the Vm is a feasible maneuver to enhance AV diameter and the success rate of USGAVA in most patients undergoing CIED implantation while maintaining safety.

A simple method of axillary venipuncture using single landmark for pacemaker leads implantation

BACKGROUND

Axillary venipuncture for pacemaker lead implantation has been demonstrated to be an effective method without fatal complications encountered with standard subclavian access approach, but the relatively high complexity limits its clinical practicability.

OBJECTIVE

We are proposing a simple technique for axillary venipuncture using single point on clavicle as anatomical landmark with the possibility of alternative fluoroscopic assisted puncture as a backup.

METHODS

Connecting point of medial to middle third of clavicle is located as the landmark. Deflected lateral 45°from sagittal line, an 18-guage needle tip is laid on the point and tangential to upper border of clavicle. Penetrated from the hub site, the needle is directed to the landmark at approximately 30-45° relative to body surface for venipuncture. If blind puncture failed, an alternative fluoroscopic method is performed. Upon successful venipuncture, a guide wire is positioned in inferior vena cava and a skin incision and subcutaneous pocket is made at the puncture site.

RESULTS

Axillary vein puncture was successful for 106 of 113 patients (93.8%) in the study with mean access time of 3.6 ± 1.4 min. In 84 patients (74.3%), the vein was cannulated by blind puncture, and fluoroscopy guided method was required in other 22 patients (19.5%). The puncture of axillary artery occurred in one patient (0.09%) and no haemorrhage was observed after local pressure. No pneumothorax, hemothorax, or brachial plexus injury was found.

CONCLUSIONS

The approach of axillary vein puncture using single landmark on the clavicle is simple, effective and safe for pacemaker lead implantation.

Case report: A rare complication after the implantation of a cardiac implantable electronic device: Contralateral pneumothorax with pneumopericardium and pneumomediastinum

Cardiac implantable electronic devices (CIED) including pacemakers (PM), implantable cardioverter defibrillators (ICD), and cardiac resynchronized therapy (CRT) have become the mainstay of therapy for many cardiac conditions, consequently drawing attention to the risks and benefits of these procedures. Although CIED implantation is usually a safe procedure, pneumothorax remains an important complication and may contribute to increased morbidity, mortality, length of stay, and hospital costs. On the other hand, pneumopericardium and pneumomediastinum are rare but potentially fatal complications. Accordingly, a high degree of awareness about these complications is important. Pneumothorax almost always occurs on the ipsilateral side of implantation. The development of contralateral pneumothorax is uncommon and may be undetected on an initial chest radiograph. Contralateral pneumothorax with concurrent pneumopericardium and pneumomediastinum is much rarer. We describe a rare case of concurrent right-sided pneumothorax with pneumopericardium and pneumomediastinum after left-sided pacemaker implantation and highlight the risk factors, management, and possible ways to prevent the complications.

How to Perform Extrathoracic Venous Access for Cardiac Implantable Electronic Devices Placement: Detailed Description of Techniques

Venous access is needed for the implantation of cardiac implantable electronic devices (CIED) 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 the 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 the relative advantages and disadvantages for each of these extrathoracic venous access sites.

Axillary vein access using ultrasound guidance, Venography or Cephalic Cutdown-What is the optimal access technique for insertion of pacing leads?

We reviewed the different approaches used for central vein access during insertion of cardiac implantable electronic devices. The benefits and hazards of each approach (cephalic vein cutdown, axillary vein cannulation using venography and ultrasound) are discussed. Each approach has its advantages and hazards that need to be considered for the individual patient and balanced against the skills of the operator. The benefits of ultrasound guided venous access in reducing radiation exposure to the patient and implanter, avoiding the need for angiographic contrast and in minimizing the risk of pneumothorax and inadvertent arterial puncture are highlighted. Trainees should be taught each approach to deal with patient variability. Ultrasound guidance should be considered as a mainstream option for most patients.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Real-time venography-guided extrathoracic puncture technique for cardiovascular implantable electronic device implantation

Central venous access is an essential technique for cardiovascular implantable electronic device (CIED) implantation, and the use of axillary vein approach has recently been increasing. This study sought to examine whether real-time venography-guided extrathoracic puncture facilitates the procedure. We retrospectively analyzed 179 consecutive patients who underwent CIED implantation using the axillary vein puncture method. Patients were divided into two groups: the conventional method group (CG, n = 107) and the real-time venography-guided group (RG, n = 82). The application of real-time venography was at the discretion of individual operators. Operators with experience of less than 50 CIED implantations were defined as inexperienced operators in this study. Puncture duration and number of attempts were significantly less in the RG group than in the CG group (283 ± 198 vs. 421 ± 361 s, p < 0.01, and 3.19 ± 2.00 vs. 4.18 ± 2.85, p < 0.01). These benefits of real-time venography were observed in inexperienced operators, but not in experienced operators. In addition, the success rate without extra attempts at puncture was higher in the RG group (54% vs. 32%, p < 0.01). Although the total amount of contrast medium was higher in the RG group (16.3 ± 4.1 mL vs. 11.9 ± 6.6 mL, p < 0.01), serum levels of creatinine pre- and post-operation were not different in the two groups (p = NS). We concluded that real-time venography is a safe and effective method for axillary vein puncture, especially in inexperienced operators.

Axillary vein access for antiarrhythmic cardiac device implantation: a literature review

The current narrative review provides an update of available knowledge on venous access techniques for cardiac implantable electronic device implantation, with a focus on axillary vein puncture. Lower procedure-related and lead-related complications have been reported with extrathoracic vein puncture techniques compared with intrathoracic accesses. In particular, extrathoracic lead access through the axillary vein seems to be associated with lower complication incidence than subclavian vein puncture and higher success rate than cephalic vein cutdown. In literature, many techniques have been described for axillary vein access. The use of contrast venography-guided puncture has facilitated the diffusion of the axillary vein approach for device implantation. Venography may be particularly useful in specific demographic and clinical device implantation contexts. Ultrasound-guided or microwire-guided vascular access for lead positioning can be considered a valid alternative to venography, although current applications for axillary vein puncture need further evaluations.

Ultrasound guided percutaneous cephalic venipuncture for implantation of cardiac implantable electronic devices

BACKGROUND

Preoperative ultrasound (US) for cephalic cut-down is related to shorter procedure time and higher success rate. This study aimed to assess efficiency of US-guided percutaneous cephalic vein (CV) puncture for placement of cardiac implantable electronic devices (CIEDs).

METHODS

Patients undergoing a procedure including both US-guided pectoral nerve block (PECS) and percutaneous CV puncture were retrospectively investigated. Patient medical history and demographic data was collected. Clinical features of the procedures and intra- and post-operative complications occurring were collected from patient records. Clinical data included target vessel features, and the time taken for the following: CV puncture; CV and PECS puncture; total procedure.

RESULTS

In total 34 patients had CV puncture with US-guided PECS block was attempted in all patients and the procedure was successful in 27 of 34 (79.4%) patients. The total number of CV puncture attempts was 62 for 34 leads (mean attempts per lead = 1.82). The mean ± standard deviation time for CV puncture was 137.5 ± 27.4 s. There were no venous access-related complications.

CONCLUSION

US-guided CV puncture appears feasible and safe with an acceptable success rate. In case of failure of the US-guided axillary or subclavian vein approach, it may be preferred as an alternative to the cephalic cut-down procedure, where the success rate is relatively lower and the risk of bleeding is higher.

The New Surface Landmarks for Blind Axillary Vein Puncture

Objective

To compare the efficacy of blind axillary vein puncture utilizing the new surface landmarks for the subclavian method.

Methods

This prospective and randomized study was performed at two cardiology medical centers in East China. Five hundred thirty-eight patients indicated to undergo left-sided pacemaker or implantable cardioverter defibrillator implantation were enrolled, 272 patients under the axillary access and 266 patients under the subclavian approach. A new superficial landmark was used for the axillary venous approach, whereas conventional landmarks were used for the subclavian venous approach. We measured lead placement time and X-ray time from vein puncture until all leads were placed in superior vena cava. Meanwhile, the rate of success of lead placement and the type and incidence of complications were compared between the two groups.

Results

There were no significant differences between the two groups in baseline characteristics or number of leads implanted. There were high success rates for both strategies (98.6% [494/501] vs. 98.4% [479/487], P=0.752) and similar complication rates (14% [38/272] vs. 15% [40/266], P=0.702). Six cases in the control group developed subclavian venous crush syndrome and five had pneumothorax, while neither pneumothorax nor subclavian venous crush syndrome was observed in the experimental group.

Conclusion

We have developed a new blind approach to cannulate the axillary vein, which is as effective as the subclavian access, safer than that, and also allows to get this vein without the guidance of fluoroscopy, contrast, or echography.

Ultrasound-guided Axillary Vein Puncture in Cardiac Lead Implantation: Time to Move to a New Standard Access?

Cardiac stimulation therapy has evolved significantly over the past 30 years. Currently, cardiac implantable electronic devices (CIED) are the mainstream therapy for many potentially lethal heart conditions, such as advanced atrioventricular block or sustained ventricular tachycardia or fibrillation. Despite sometimes being lifesaving, the implant is surgical and therefore carries all the inevitable intrinsic risks. In the process of technology evolution, one of the most important factors is to make it safer for the patient. In the context of CIED implants, complications include accidental puncture of intrathoracic structures. Alternative strategies to intrathoracic subclavian vein puncture include cephalic vein dissection or axillary vein puncture, which can be guided by fluoroscopy, venography or, more recently, ultrasound. In this article, the authors analyse the state of the art of ultrasound-guided axillary vein puncture using evidence from landmark studies in this field.

Vein Management for Cardiac Device Implantation

Transvenous approaches for pacemaker and defibrillator lead insertion offer numerous advantages over epicardial techniques. Although the cephalic, axillary, and subclavian veins are most commonly used in clinical practice, they each offer their own set of advantages and disadvantages that leave their usage dependent on patient anatomy and physician preference. Alternative methods using the upper and lower venous circulation have been described when these veins are not available or practical for lead insertion. Until current technology is superseded by leadless pacing systems, the search for the optimal lead insertion technique continues.

The anatomical relationship between the axillary artery and vein investigated by radial coronary angiography

AIMS

To reduce the risk of inadvertent arterial puncture and bleeding, we aimed to define a safe puncture site by demonstrating the relation of the axillary artery and vein.

METHODS

The anatomical course and relation as well as crossover sites of the axillary artery and vein, the presence of small arterial bridges over the axillary vein, and validation of commonly preferred axillary venous puncture sites were determined by simultaneous ipsilateral venography in patients (n  =  111; 80 men, age 60 ± 10 years) who underwent coronary angiography by radial artery access.

RESULTS

The axillary vein was detected at the first costa-clavicular intersection in 62% and at the second anterior and third posterior costal intersection in 60% of the patients. Small arterial bridges over the axillary vein were observed in 77% of the patients and more frequently in females and body mass index ≥25 kg/m2 (P  =  0.034 and P  =  0.03, respectively). The axillary artery crossed the vein in 24% of the patients and almost always within the region close to the first costa-clavicular intersection site.

CONCLUSION

Our study demonstrated a high crossover rate (24%) of axillary artery and vein and a high degree of variation in the course of axillary vein. Small arterial bridges over the axillary vein were observed in 77% of the patients.

Extrathoracic subclavian-axillary vein location and morphological features over the first rib for pacemaker and defibrillator lead implantation

BACKGROUND

We aimed to describe the variations of extrathoracic subclavian-axillary vein location and its morphology over the first rib by venography in order to facilitate venous puncture using fluoroscopic landmarks without contrast venography, and evaluate the success rate of punctures, which is made with our method.

METHODS

Patients who had undergone de novo lead implantation with the help of prepuncture venography between 2011 and 2015 were enrolled. For detection of the segmental location of the axillary vein, the zones were defined (Zone 1: Posterior, Zone 2: Lateral, Zone 3: Medial) at the first rib by fluoroscopy. Additionally, patients, who underwent venous puncture with our method after January 2017, were evaluated in terms of puncture success.

RESULTS

Four hundred thirty-three patients who had prepuncture contrast venography for defibrillator or pacemaker lead implantation in 2011-2015 were analyzed. The most common position of the axillary vein was found to be over zone 2 (91%) while the zone 1 location was 8.5% and the zone 3 was 0.5%. Venous valves were detected on the first rib in 98 patients. After January 2017, venous puncture using fluoroscopic landmarks was performed to 171 patients. The punctures were successfully performed over zone 2 with our method in 90.7% of the patients.

CONCLUSIONS

The most common radioanatomic position of the extrathoracic subclavian-axillary vein was observed at zone 2 according to our method and the probability of presence of venous valve over the first rib is 22%. Additionally, the success rate of puncture using fluoroscopic landmarks over zone 2 was 90.7%.

Puncture of the Axillary Vein for the Implant for Electronic Cardiac Devices

Introduction: The obtaining of venous access for implantation of implantable electronic cardiac devices (IECDs) has been traditionally made by intrathoracic subclavian vein puncture (SVP) or cephalic vein phlebotomy (CVP). Evidence indicates, however, the increased risk of short-term and long-term complications with SVP due to the fact that it is intrathoracic access and the risk of compression of the electrodes by the costoclavicular ligament, leading to different types of defects. CVP, in turn, has been associated with a failure rate that reaches 45%. Axillary vein puncture (AVP) has been described in the literature and is presented here as an alternative to the two techniques mentioned. Methods: A PubMed survey was conducted on articles that mention the AVP, SVP and CVP techniques and compare them to the immediate, short and long term results and success rates for obtaining venous access. Emphasis was placed on comparisons between the various AVP techniques. Conclusion: The AVP technique for obtaining venous access presents some variations among the different authors. It has CVP-like safety, success rates comparable to those of the subclavian vein, and better medium and long term results for electrode function.

Punção da Veia Axilar para o Implante de Dispositivos Cardíacos Eletrônico

Introdução: A obtenção do acesso venoso para implante de dispositivos cardíacos eletrônicos implantáveis (DCEIs) tem sido tradicionalmente feita por meio da punção da veia subclávia intratorácica (PVS) ou por fl ebotomia da veia cefálica (FVC). Evidências apontam, entretanto, para o risco aumentado de complicações a curto e longo prazos com a PVS pelo fato de ser um acesso intratorácico e pelo risco de compressão dos eletrodos pelo ligamento costoclavicular, levando a diferentes tipos de defeitos. A FVC, por sua vez, tem sido associada à taxa de insucesso que chega a 45%. A punção da veia axilar (PVA) tem sido descrita na literatura e é apresentada, aqui, como alternativa às duas técnicas mencionadas. Métodos: Realizou-se uma pesquisa pelo PubMed sobre artigos que mencionam as técnicas de PVA, PVS e FVC e que as comparam quanto aos resultados imediatos, a curto e longo prazos e taxas de sucesso para a obtenção do acesso venoso. Deu-se ênfase às comparações entre as diversas técnicas de PVA. Conclusão: A técnica de PVA para obtenção do acesso venoso apresenta algumas variações entre os diversos autores. Ela tem segurança semelhante à da FVC, taxas de sucesso comparáveis às da veia subclávia e melhores resultados a médio e a longo prazos para a função dos eletrodos.

Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients

BACKGROUND

Pneumothorax (PTX) is a potential complication of vascular access during cardiac implantable electronic device (CIED) procedures and is being scrutinized as a health care-acquired condition.

OBJECTIVE

The purpose of this study was to determine the trends in PTX incidence in the United Stated over a 16-year period and to determine whether PTX is associated with increased mortality after adjustment for other factors.

METHODS

Using weighted sampling in the largest inpatient health database in the United States (National Inpatient Sample), we evaluated data from patients with a primary procedure of CIED implantation from 1998 to 2013 who had at least 1 new vascular access (new or upgrade of prior CIED). The unadjusted and adjusted associations of PTX with mortality and other parameters were examined.

RESULTS

Among 3,764,703 CIED procedures, PTX occurred in 47,839 cases (1.3%). The apparent incidence of PTX peaked at 1.6% in 2012 and 2013, although this result may have been affected by a concomitant decrease of inpatient (vs outpatient) CIED. PTX was significantly associated with pulmonary complications, chest tube insertion, length of stay, and costs. Mortality was statistically higher in patients with PTX (1.2% vs 0.7%; P <.001), a relationship that remained significant in a multivariate logistic regression analysis (odds ratio 1.50, 95% confidence interval 1.36-1.65; P <.001). Age >80 years, female gender, Caucasian race, chronic obstructive pulmonary disease, and dual-chamber (vs single-chamber) device were all associated with higher odds for PTX occurrence. Placement of a chest tube was a major determinant of worse outcomes and higher costs.

CONCLUSION

PTX remains an important complication of CIED procedures and is associated with increased morbidity, mortality, and costs.

Optimized Axillary Vein Technique versus Subclavian Vein Technique in Cardiovascular Implantable Electronic Device Implantation: A Randomized Controlled Study

BACKGROUND

The conventional venous access for cardiovascular implantable electronic device (CIED) is the subclavian vein, which is often accompanied by high complication rate. The aim of this study was to assess the efficacy and safety of optimized axillary vein technique.

METHODS

A total of 247 patients undergoing CIED implantation were included and assigned to the axillary vein group or the subclavian vein group randomly. Success rate of puncture and complications in the perioperative period and follow-ups were recorded.

RESULTS

The overall success rate (95.7% vs. 96.0%) and one-time success rate (68.4% vs. 66.1%) of punctures were similar between the two groups. In the subclavian vein group, pneumothorax occurred in three patients. The subclavian gaps of three patients were too tight to allow operation of the electrode lead. In contrast, there were no puncture-associated complications in the axillary vein group. In the patient follow-ups, two patients in the subclavian vein group had subclavian crush syndrome and both of them received lead replacement. The incidence of complications during the perioperative period and follow-ups of the axillary vein group and the subclavian vein group was 1.6% (2/125) and 8.2% (10/122), respectively (χ2 = 5.813, P = 0.016).

CONCLUSION

Optimized axillary vein technique may be superior to the conventional subclavian vein technique for CIED lead placement.

TRIAL REGISTRATION

www.clinicaltrials.gov, NCT02358551; https://clinicaltrials.gov/ct2/show/NCT02358551?term=NCT02358551& rank=1.

Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 Implantable Cardioverter-Defibrillator Guidelines

Sudden cardiac death is a major public health issue in Canada. However, despite the overwhelming evidence to support the use of implantable cardioverter defibrillators (ICDs) in the prevention of cardiac death there remains significant variability in implantation rates across Canada. Since the most recent Canadian Cardiovascular Society position statement on ICD use in Canada in 2005, there has been a plethora of new scientific information to assist physicians in their discussions with patients considered for ICD implantation to prevent sudden cardiac death due to ventricular arrhythmias. We have reviewed, critically appraised, and synthesized the pertinent evidence to develop recommendations regarding: (1) ICD implantation in the primary and secondary prevention of sudden cardiac death in patients with and without ischemic heart disease; (2) when it is reasonable to withhold ICD implantation on the basis of comorbidities; (3) ICD implantation in patients listed for heart transplantation; (4) implantation of a single- vs dual-chamber ICD; (5) implantation of single- vs dual-coil ICD leads; (6) the role of subcutaneous ICDs; and (7) ICD implantation infection prevention strategies. We expect that this document, in combination with the companion article that addresses the implementation of these guidelines, will assist all medical professionals with the care of patients who have had or at risk of sudden cardiac death.

Wireless Ultrasound-Guided Axillary Vein Cannulation for the Implantation of Cardiovascular Implantable Electric Devices

INTRODUCTION

Ultrasound guidance for vascular cannulation seems safer and more effective than an anatomical landmark approach, though it has not gained widespread support partly due to workflow interference of wired probes. A wireless ultrasound transducer (WUST) may overcome this issue. We report the effectiveness, time consumption, and safety of the first-in-human experience in axillary vein cannulation guided with a novel WUST for the implantation of cardiovascular implantable electric devices (CIEDs).

METHODS AND RESULTS

After a one-month training period, we routinely performed WUST-guided puncture to all first implants, prospectively registering data from the first 50 patients. We analyzed the time needed for preparing the WUST and for achieving each vein cannulation, and the rate of unsuccessful or accidental arterial punctures and complications. WUST-guided axillary vein access was successful in 49 out of 50 patients, totaling 86 cannulated veins. Median WUST preparation time was 55 [44-62] seconds and median time needed for each venous cannulation was 56 [36-71] seconds. A total of 84.9% of the veins were cannulated at the first attempt. There were 7 unsuccessful puncture attempts and 1 accidental arterial puncture. No pneumothorax, hemothorax, or nervous injury occurred in the 49 successfully cannulated patients. The unsuccessful one (distal subclavian occlusion) developed a minor local subcutaneous emphysema with no confirmed radiologic pneumothorax, not requiring intervention. During a follow-up of 2.5 ± 1.1 months, a patient developed a pocket infection, with no other significant complications.

CONCLUSION

Ultrasound-guided axillary vein cannulation using a wireless transducer for the implantation of CIEDs is a feasible, fast, and safe method.

A Case of Transvenous Pacemaker Implantation in a 10-year-old Patient

Objective: The aim of this report was to discuss the type, timing, and surgical techniques of permanent pacemaker implantation in a juvenile patient.

Patients: A 17-year-old girl with Down syndrome and congenital heart defects comprised of ventricular septal defects (VSD) and patent ductus arteriosus (PDA) suffered from postoperative complete atrioventricular block (AVB) when she was 7 months old.

Methods and Results: An epicardial pacemaker was implanted just after the occurrence of complete AVB. Due to the pacing threshold of a ventricular lead not being good, the battery showed rapid depletion. Her generator had to be exchanged under general anesthesia every 2–3 years. When she was 10 years old, we implanted a permanent pacemaker transvenously by using cutdown, screw-in and subpectoral pocket techniques. She has shown a satisfactory outcome since then.

Conclusion: Transvenous pacemaker implantation was safe and effective in our young patient without any complications. The timing of surgery and surgical technique are quite important for pacemaker implantation in juvenile patients.