Ultrasound-Guided Venous Axillary Access Versus Standard Fluoroscopic Technique for Cardiac Lead Implantation: ZEROFLUOROAXI Randomized Trial

Ultrasound-Guided Axillary Vein Puncture for Cardiac Device Implantation: A Systematic Review and Meta-Analysis

Ultrasound-guided axillary vein puncture (US-AVP) has recently emerged as a valid alternative to standard vein puncture (SVP) for cardiac implantable electronic device implantation. This meta-analysis aimed to compare the efficacy and safety of US-AVP versus SVP. A comprehensive search of PubMed, Embase, and Cochrane databases identified randomized clinical trials and nonrandomized clinical trials comparing these techniques. Pooled relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random- or fixed-effects models, and trial sequential analysis was conducted to assess the robustness of findings. Twelve studies met the inclusion criteria, including 3085 patients (1227 in the US-AVP group and 1858 in the SVP group). US-AVP significantly reduced total complication rates compared with SVP [RR, 0.65 (95% CI, 0.48-0.89); P = 0.006; I² = 0%], with no significant difference in success rates [RR, 1.05 (95% CI, 0.99-1.11); P = 0.137; I² = 60%]. Fluoroscopy duration was significantly shorter in the US-AVP group [MD, -1.58 min (95% CI, -2.16 to -0.99); P < 0.001; I² = 81%], and X-ray exposure was markedly lower [MD, -3.23 mGy·cm² (95% CI, -6.03 to -0.43); P = 0.024; I² = 93%]. The trial sequential analysis supported the robustness of the evidence for reduced complications. In conclusion, US-AVP demonstrated a safety advantage over SVP by reducing complications while achieving comparable efficacy.

Ultrasound-guided vs. fluoro-guided axillary venous access for cardiac implantable electronic devices: a patient-based meta-analysis

AIMS

The use of ultrasound (US)-guided venous puncture for cardiac pacing/defibrillation lead placement may minimize the risk of periprocedural complications and radiation exposure. However, none of the published studies have been sufficiently powered to recommend this approach as the standard of care. We compare the safety and efficacy of ultrasound-guided axillary venous puncture (US-AVP) vs. fluoroscopy-guided access for cardiac implantable electronic devices (CIEDs) by performing an individual patient data meta-analysis based on previously published studies.

METHODS AND RESULTS

We conducted a thorough literature search encompassing longitudinal investigations (five randomized and one prospective studies) reporting data on X-ray-guided and US-AVP for CIED procedures. The primary endpoint was to compare the safety of the two techniques. Secondary endpoints included the success rate of each technique, the necessity of switching to alternative methods, the time needed to obtain venous access, X-ray exposure, and the occurrence of periprocedural complications. Six longitudinal eligible studies were identified including 700 patients (mean age 74.9 ± 12.1 years, 68.4% males). The two approaches for venous cannulation showed a similar success rate. The use of an X-ray-guided approach significantly increased the risk of inadvertent arterial punctures (OR: 2.15, 95% CI: 2.10-2.21, P = 0.003), after adjustment for potential confounders. Conversely, a US-AVP approach reduces time to vascular access, radiation exposure, and the number of attempts to vascular access.

CONCLUSION

The US-AVP enhances safety by reducing radiation exposure and time to vascular access while maintaining a low rate of major complications compared to the X-ray-guided approach.

CLINICAL TRIAL REGISTRATION

PROSPERO identifier: CRD42024539623.

Ultrasound-guided versus fluoroscopy-guided axillary vein puncture for cardiac implantable electronic device implantation: a meta-analysis enrolling 1257 patients

INTRODUCTION

Ultrasound-guided (Echo-AVP) and Fluoroscopy-guided Axillary Vein Puncture (Fluoro-AVP) are both acknowledged as safe and effective techniques for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile. Therefore, we performed a meta-analysis to evaluate the efficacy and safety of Echo-AVP versus Fluoro-AVP for CIEDs implantation.

METHODS

We systematically searched Medline, Embase and Cochrane electronic databases up to May 15th, 2024, for studies that evaluated the efficacy and safety of Echo-AVP and Fluoro-AVP reporting at least one clinical outcome of interest. The primary efficacy endpoint was acute procedural success and the primary safety endpoint was a composite endpoint of pneumothorax, pocket hematoma/bleeding, pocket infection and inadvertent arterial puncture. The effect size was estimated using a random-effect model as Odds Ratio (OR) and Mean Difference (MD) with relative 95% Confidence Interval (CI).

RESULTS

Overall, 4 studies were included, which enrolled 1257 patients (Echo-AVP: 373 patients; Fluoro-AVP: 884 patients). Echo-AVP led to a significant reduction in the primary safety endpoint (OR: 0.41; p = 0.0009), risk of inadvertent arterial puncture (OR: 0.29; p = 0.003) and fluoroscopy time ( MD: -105.02; p = 0.008). No differences were found between Echo-AVP and Fluoro-AVP for acute procedural success (OR: 0.77; p = 0.27), pneumothorax (OR: 0.66; p = 0.60), pocket hematoma/bleeding (OR: 0.68; p = 0.30), pocket infection (OR: 0.66; p = 0.60), procedural time (MD: 1.99; p = 0.65), success rate at first attempt (OR: 1.25; p = 0.34) and venous access time (MD: -0. 25; p = 0.99).

CONCLUSION

Echo-AVP proved to reduce significantly the primary safety endpoint, inadvertent arterial puncture and fluoroscopy time compared to Fluoro-AVP.