SAFETY AND EFFECTIVENESS OF PLACEMENT OF PACEMAKER AND DEFIBRILLATOR LEADS IN THE AXILLARY VEIN GUIDED BY CONTRAST VENOGRAPHY

Despite evidence of an increased incidence of lead fracture, the infra clavicular subclavian approach remains the dominant approach for place ment of pacemaker and implantable defibrillator leads. Although this c omplication can be prevented by lead placement in the cephalic vein or by recently described approaches for lead placement in the axillary v ein, these approaches have not gained widespread acceptance. The purpo se of this study was to evaluate the safety and efficacy of an alterna tive technique for lead placement that uses contrast-guided venipunctu re of the axillary vein with a 5Fr micropuncture introducer set, A fet al of 50 patients underwent an attempt at placement of pacemaker or im plantable defibrillator leads via the axillary vein using this new tec hnique. Patients were randomized into 2 groups based on whether the in itial attempt at axillary vein access was performed medial or lateral to the rib cage margin. Leed placement was successfully accomplished i n 49 of the 50 patients using this technique. initial success was achi eved in each of 25 patients randomized to the medial approach compared with 18 of 24 patients randomized to the lateral approach to the axil lary vein (75%). In each of the 6 patients in whom the initial techniq ue failed, lead placement was subsequently achieved with the medial ap proach. In addition to a higher initial success rate, the medial appro ach was determined to be preferable as evidenced by a shorter lead pla cement time, a smaller number of contrast injections, and a reduced re quirement for additional micropuncture guidewires. There were no major complications associated with either approach. Contrast-guided venipu ncture of the axillary vein is a safe and effective approach to placem ent of endocardial leads. (C) 1997 by Excerpta Medica, Inc.