title: Axillary vein puncture using fluoroscopic landmarks: a safe and effective approach for implantable cardioverter defibrillator leads.
abstract: OBJECTIVE
  Axillary vein puncture is an effective method for pacemaker lead insertion with less complications compared with subclavian vein puncture; however, there are limited data on implantable cardioverter defibrillator (ICD) implantation with this technique. We reported our experience with a blind axillary vein puncture using fluoroscopic landmarks consisting of the outer edge of the first rib and the body surface of the second rib for ICD lead implantation.
  
  
  METHODS
  The study population included 103 consecutive patients (mean age 59 ± 9 years) referred for ICD implantation using axillary vein puncture without contrast venography. An 18-gauge needle was advanced toward the outer edge of the fist rib below the clavicle or the body surface of the second rib. If the vein was not entered, the needle was withdrawn and the puncture was repeated with slight variations of needle direction for a maximum of four times, then contrast-guided vein puncture was performed.
  
  
  RESULTS
  The total implanted leads were 152 including 103 right ventricular leads, 35 right atrial leads, and 14 left ventricular epicardial leads. Blind axillary vein puncture was successful obtained in 96 (93.2 %) patients. The rate of success was higher using the body surface of the second rib compared with the outer edge of the first rib (88.7 vs. 100 %; p = 0.04).Contrast venography was required in seven (6.8 %) patients because of vein course abnormality (n = 5) or vasospasm (n = 2). No acute complications or device-related complications were recorded during a mean follow-up of 12 ± 5 months.
  
  
  CONCLUSIONS
  Axillary vein access using fluoroscopic landmarks, especially the body surface of the second rib, is an effective approach for ICD implantation and offers the potential to avoid complications usually observed with traditional subclavian vein approach.
authors.affiliation: Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Via N. Giustiniani 2, 35128, Padova, Italy, federico.migliore@libero.it.
authors.forename: Federico
authors.initials: F
authors.lastname: Migliore
authors.forename: Mariachiara
authors.initials: M
authors.lastname: Siciliano
authors.forename: Manuel
authors.initials: M
authors.lastname: De Lazzari
authors.forename: Sonia
authors.initials: S
authors.lastname: Ferretto
authors.forename: Chiara Dalla
authors.initials: CD
authors.lastname: Valle
authors.forename: Alessandro
authors.initials: A
authors.lastname: Zorzi
authors.forename: Domenico
authors.initials: D
authors.lastname: Corrado
authors.forename: Sabino
authors.initials: S
authors.lastname: Iliceto
authors.forename: Emanuele
authors.initials: E
authors.lastname: Bertaglia
mesh_terms: D059925:Anatomic Landmarks / Q000000981:diagnostic imaging*; D001367:Axillary Vein / Q000000981:diagnostic imaging / Q000601:surgery*; D017147:Defibrillators, Implantable; D004567:Electrodes, Implanted; D005260:Female; D005471:Fluoroscopy / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography / Q000379:methods; D019919:Prosthesis Implantation / Q000379:methods*; D011677:Punctures / Q000379:methods*; D015641:Radiography, Interventional / Q000379:methods*; D015203:Reproducibility of Results; D012272:Ribs / Q000000981:diagnostic imaging; D012680:Sensitivity and Specificity; D016896:Treatment Outcome