Axillary vein puncture without contrast venography for pacemaker and defibrillator leads implantation.

BACKGROUND Axillary vein puncture has been demonstrated to be an effective method for pacemaker and defibrillator leads implantation, without the complications encountered with the standard intrathoracic approach. OBJECTIVE Different techniques have been adopted for the cannulation of the axillary vein. We report our experience using the outer edge of the first rib below the inferior border of the clavicle as fluoroscopic landmark. METHOD A subcutaneous pocket is created 1-cm medially and parallel to the delto-pectoral groove and 2 cm below the clavicle. An 18-gauge needle from the upper border of the pocket is directed perpendicularly to the outer edge of the first rib just below the inferior border of the clavicle. If the vein is not entered, the needle is withdrawn and the puncture is repeated with slight variations of needle direction for a maximum of four to five times, then contrast-guided vein puncture is performed. Upon successful vein puncture, a guidewire is inserted and positioned in the superior vena cava. The remainder of the implantation is carried out in a routine manner. RESULTS The axillary vein was successfully cannulated without venography in 172 of 182 consecutive patients (94.5%); the vein could not be found in 10 patients (5.5%): in these patients the vein was successfully cannulated after venography performance. No pneumothorax, hemothorax, or brachial plexus injury occurred. CONCLUSIONS Our approach of axillary venipunture using fluoroscopic landmark, without contrast venography, is simple, safe, and effective.