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Year : 2018  |  Volume : 3  |  Issue : 3  |  Page : 104-107

Safety and efficacy of a modified axillary vein technique for pacemaker implantation

Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China

Date of Web Publication24-Sep-2018

Correspondence Address:
Shenghua Zhou
Department of Cardiology, The Second Xiangya Hospital of Central South University, Renmin Road, No. 139, Changsha, Hunan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cp.cp_21_18

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Context: Axillary vein puncture is an alternative method for pacemaker leads implantation. However, the safety and effectiveness of axillary vein puncture become an issue for debate now. Aims: The aim of this study was to investigate the safety, feasibility, and efficacy of a modified axillary vein technique for pacemaker implantation. Settings and Design: This modified axillary vein technique refers to a novel axillary vein puncture method combined with caudal 35° fluoroscopy and surface anatomic landmarks including deltopectoral groove, coracoid process, and the first rib. Subjects and Methods: This technique was applied to 139 consecutive patients referred for pacemaker implantation between March 1, 2016, and December 31, 2016, at our department. Statistical Analysis Used: None. Results: Success rate of pacemaker implantation was 96.4% (134/139). Five patients (3.60%) were switched to an alternate approach for leads implantation. There were no procedure-related complications such as pneumothorax, hemopneumothorax, major bleeding, and significant pocket hematoma. Conclusion: This modified axillary vein puncture strategy combining caudal 35° fluoroscopy and surface anatomic landmarks is safe and feasible for pacemaker implantation.

Keywords: Axillary vein, caudal fluoroscopy, coracoid process, deltopectoral groove, pacemaker implantation

How to cite this article:
Yang H, Jiang H, Liu Q, Zhou S, Li X, Liu Z, Wu Z, Wu C. Safety and efficacy of a modified axillary vein technique for pacemaker implantation. Cardiol Plus 2018;3:104-7

How to cite this URL:
Yang H, Jiang H, Liu Q, Zhou S, Li X, Liu Z, Wu Z, Wu C. Safety and efficacy of a modified axillary vein technique for pacemaker implantation. Cardiol Plus [serial online] 2018 [cited 2019 Jul 16];3:104-7. Available from: http://www.cardiologyplus.org/text.asp?2018/3/3/104/242079

  Introduction Top

Cardiac pacemaker implantation is a common clinical practice, and demand for pacemaker implantation increases year by year with aging population.[1],[2] The subclavian vein puncture is the most widely used method for pacemaker implantation; however, this technique is associated with potentially severe complications including pneumothorax, hemopneumothorax, brachial plexus injury, and subclavian crush syndrome, which will lead to bad clinic consequences.[3],[4] The cephalic vein is another common access for pacemaker implantation, but this vein is too small and not suitable for multiple leads insertion and implantable cardioverter-defibrillator implantation.[5] The femoral vein was also adopted in recent trials for leadless pacemaker.[6],[7] Axillary venous access is an ideal alternative strategy for pacemaker implantation. In 1999, Belott proposed a blind axillary vein puncture technique with a high success rate using anatomic landmarks.[8] Nonetheless, in the initial Belott's method, the needle tip was aimed downward, toward the lung, which would potentially increase the risk of pneumothorax. In the year of 2006, Belott introduced a modified method of axillary vein access relying on superficial anatomy and fluoroscopy of the first rib.[9] Recently, Yang and Kulbak reported that use of the caudal 35° fluoroscopic view could help to avoid the risk of pneumothorax in the process of axillary vein puncture.[10] However, the puncture site was not defined before incision by this method; this might potentially decrease the success rate of using this implantation method in daily clinical practice since most operators prefer to first achieve the successful puncture before incision and creation of pocket for pacemaker.

  Subjects and Methods Top

This study was approved by the Central South University Ethics Committee for Human Research from The Second Xiangya Hospital (Changsha, China). Patient consent forms were obtained from all cases before this research. In view of the limitations of traditional axillary vein puncture techniques described above, we made some modifications to Belott's [4] and Yang's [5] methods. Briefly, the deltopectoral groove was palpated and its location and direction were noted. Also, the coracoid process (CP) and infraclavicular space were carefully identified. As shown in [Figure 1] and [Figure 2], an assumed line was made from CP to the medial perpendicular to the deltopectoral groove. The puncture site was set at about 1–2 cm away from CP on the assumed line. After local anesthesia with lidocaine, negative pressure was applied on the micropuncture needle using a 20-ml syringe. The needle was advanced parallel to the deltopectoral groove at an angle of 30°–45° to the skin according to patients' body habitus [Figure 3]. At the same time, the fluoroscopy camera was moved to 35° caudal to show the margin of the lung and the first rib [Figure 4]. At this view, the needle was moved toward the lateral of the first rib. For obese patients, one operator's thumb should press around the infraclavicular space to facilitate the needle moving toward the axillary vein. After the puncture needle entered the axillary vein, a guidewire was advanced from the tail part of the puncture needle [Figure 4]. When the wire was advanced into the inferior vena cava under the guidance of anterior–posterior fluoroscopy, an incision (about 4 cm) was made horizontally from the puncture site toward the sternum pacemaker after repeated local anesthesia to create the pocket for pacemaker. Occasionally, the needle was required to withdraw and advanced again with slight adjustments on the puncture angle or the needle was moved from medial to lateral along the first rib until venous access was achieved.
Figure 1: This figure shows how to localize the puncture site using surface landmarks. The patient is lying on a supine position. The clavicle, CP, and deltopectoral groove are illustrated. A line is made perpendicular to the deltopectoral groove from the CP and the puncture site is about 2 cm away from the CP vertical to the deltopectoral groove. CP: Coracoid process

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Figure 2: The fluoroscopy AP view shows the spatial orientation of the axillary vein. The axillary vein is the continuation of the subclavian vein from the lateral border of the first rib. AP: Anterior–posterior, SV: Subclavian venae, and CP: Coracoid process

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Figure 3: This figure shows the 30°–45° angle between the syringe and the horizontal plane

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Figure 4: This figure shows the anatomic relationship between the puncture needle and the first rib of a patient undergoing double-chamber pacemaker implantation in caudal 35° view. The puncture needle, which is far away from the first rib and the thoracic chamber, was advanced into the axillary vein, as evidenced by the wire in the SVC. SVC: Superior vena cava

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  Results Top

A total of 139 consecutive patients referred for pacemaker implantation, between March 1, 2016, and December 31, 2016, were included and underwent pacemaker implantation with this modified axillary vein puncture method. Among the 139 patients, 70 were female and the average age of patients was 59.50 ± 11.53 years. One hundred (71.94%) patients underwent permanent pacemaker (PPM) implantation, while 39 (28.06%) patients underwent temporary pacemaker (TPM) implantation. Right-sided implantations were performed in seven patients receiving PPM and all 39 patients receiving TPM. Axillary vein puncture was successfully achieved in 134 (96.40%) patients. Only five patients (3.60%) required an alternate strategy (subclavicle vein puncture, four from the same side and one from the opposite side) to ultimately achieve venous access. Reason for the initial failure of venous access with the use of this modified implantation method was angiography-evidenced axillary vein vasospasm in all these five patients [Figure 5]. No significant pocket hematoma, pneumothorax, hemopneumothorax, major bleeding, or other severe complications occurred during or after the operation.
Figure 5: Angiography shows severe axillary vein vasospasm in anterior–posterior view

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  Discussion Top

The present study shows satisfactory results of pacemaker implantation with the modified implantation technique.

Success rate

The total success rate was 96.4% with this modified axillary vein technique for pacemaker implantation, which is an acceptable high success rate in comparison with the current practiced clinical implantation techniques. Comparable to the reported 98.2% success rate by the blinded axillary vein puncture method,[8] another research disclosed a success rate of 88% by ultrasound-guided venous access for PPM leads.[11] In X-ray guided strategy, such as using the outer edge of the first rib as a fluoroscopic landmark, the success rate was 94.50%, and this rate could be improved to 100% if angiography was adopted to show the anatomy of axillary vein.[12] Furthermore, other cardiologists adopted body surface of the second rib as a landmark and obtained a high success rate as well.[13] Another report of axillary vein puncture using the 35° caudal view implied a success rate of 96.1%,[10] which is very similar to our strategy. All these methods showed a high success rate of approximately or more than 90%, indicating the usefulness and reliability of axillary vein puncture strategy for pacemaker implantation in clinical practice.

Rational for modification

Our strategy is originated from the method described by Belott;[3],[9] this method highlights the use of the first rib for orientation under fluoroscopy to avoid the rare incidence of pneumothorax. The major difference between present technique and Bellot's method is the application of the caudal 35° fluoroscopy to clearly illustrate the border of lung and the first rib and hence this modification is helpful to minimize the risk of pulmonary complications such as pneumothorax and hemopneumothorax. Although Yang and Kulbak have shown that the 35° caudal view could reduce pulmonary complications when performing axillary vein puncture, the puncture site was not exactly determined before incision and the incision was already done before venous puncture.[10] In case of axillary vein vasospasm in the incision side, another incision must be made on the other side, and this extra incision could be avoided with our approach since we can freely choose alternate strategies for pacemaker implantation without the need of making two incisions.

Technical considerations

Caution is needed to avoid the damage of axillary artery because there is a potential risk of producing arteriovenous fistula. The spatial relation between the axillary vein and axillary artery is very close. In the caudal view, the axillary artery and axillary vein are nearly in the same plane [Figure 6]. If the puncture site is not exactly indicated in advance, a relative low puncture site would lead the needle tip passing through axillary vein and then entering axillary artery, resulting in arterial damage. Coincidental variation of the axillary artery is another issue of caution.[14] In the present study, the incision was made medial to the puncture site. Thus, there was an adequate distance from the shoulder joint and had little influence on the activity of the upper limb. If the incision is made at the deltopectoral groove, one should be cautious of not inducing damage on the activity of the upper limb.[10]
Figure 6: Angiography shows a wire in the artery, indicating that the axillary artery and axillary vein are in the same plane under caudal 35° view

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Technical limitations

This is our primary attempt for the axillary vein puncture using this new technique. The average time spent in the puncture is slightly longer than a conventionally used method such as subclavical vein approach. Since X-ray is incorporated in this procedure, the fluoroscopic time is slightly longer in this newly introduced strategy. We hope, in the future, when we are more skillful in this method, these disadvantages could be reduced to a minimum.

  Conclusion Top

Our study results indicate that the modified axillary vein puncture strategy combining caudal 35° fluoroscopy and surface anatomic landmarks is safe and feasible for pacemaker implantation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


This work was supported by the grant from the National Natural Science Foundation of China No. 81670269 and No. 81500355. We thank Dr. Ahmed Salah from the Suez Canal University in Egypt and Nathan Shatz from Guangzhou Weiming International School for their help with English language editing.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, et al. Trends in permanent pacemaker implantation in the United States from 1993 to 2009: Increasing complexity of patients and procedures. J Am Coll Cardiol 2012;60:1540-5.  Back to cited text no. 1
Yang H, Mohamed AS, Zhou SH. Oxidized low-density lipoprotein, stem cells, and atherosclerosis. Lipids Health Dis 2012;11:85.  Back to cited text no. 2
Migliore F, Curnis A, Bertaglia E. Axillary vein technique for pacemaker and implantable defibrillator leads implantation: A safe and alternative approach? J Cardiovasc Med (Hagerstown) 2016;17:309-13.  Back to cited text no. 3
Yang C, Shu C, Li M, Li Q, Kopp R. Aberrant subclavian artery pathologies and kommerell's diverticulum: A review and analysis of published endovascular/hybrid treatment options. J Endovasc Ther 2012;19:373-82.  Back to cited text no. 4
Liu QM, Bai ZL, Liu ZJ, Li XP, Zhou SH. Defibrillation threshold testing: Is it necessary during implantable cardioverter-defibrillator implantation? Med Hypotheses 2009;72:147-9.  Back to cited text no. 5
Xiao Y, Zhou S, Liu Q. A leadless cardiac pacemaker. N Engl J Med 2016;374:593-4.  Back to cited text no. 6
Wu D, Song D, Ni J, Dai R. Avascular necrosis of the femoral head due to the bilateral injection of heroin into the femoral vein: A case report. Exp Ther Med 2013;6:1041-3.  Back to cited text no. 7
Belott PH. Blind axillar venous access. Pacing Clin Electrophysiol 1999;22:1085-9.  Back to cited text no. 8
Belott P. How to access the axillary vein. Heart Rhythm 2006;3:366-9.  Back to cited text no. 9
Yang F, Kulbak G. A new trick to a routine procedure: Taking the fear out of the axillary vein stick using the 35 caudal view. Europace 2015;17:1157-60.  Back to cited text no. 10
Jones DG, Stiles MK, Stewart JT, Armstrong GP. Ultrasound-guided venous access for permanent pacemaker leads. Pacing Clin Electrophysiol 2006;29:852-7.  Back to cited text no. 11
Antonelli D, Feldman A, Freedberg NA, Turgeman Y. Axillary vein puncture without contrast venography for pacemaker and defibrillator leads implantation. Pacing Clin Electrophysiol 2013;36:1107-10.  Back to cited text no. 12
Migliore F, Siciliano M, De Lazzari M, Ferretto S, Valle CD, Zorzi A, et al. Axillary vein puncture using fluoroscopic landmarks: A safe and effective approach for implantable cardioverter defibrillator leads. J Interv Card Electrophysiol 2015;43:263-7.  Back to cited text no. 13
Konarik M, Kachlik D, Baca V. A coincidental variation of the axillary artery: The brachioradial artery and the aberrant posterior humeral circumflex artery passing under the tendon of the latissimus dorsi muscle. Bosn J Basic Med Sci 2014;14:239-43.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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