Subcutaneous Versus Transvenous Implantable Cardioverter-Defibrillators in End-Stage Renal Disease: A Real-World Study.

BACKGROUND

Patients with end-stage renal disease (ESRD) on dialysis face a high risk of sudden cardiac death, but traditional transvenous implantable cardioverter-defibrillators (TV-ICD) carry risks of central venous stenosis and infection. Subcutaneous implantable cardioverter-defibrillators (S-ICD) provide an extravascular alternative, though comparative outcomes in dialysis patients remain limited.

METHODS

This study evaluated ESRD patients on hemodialysis who underwent S-ICD or TV-ICD implantation between January 2000 and March 2026 using the TriNetX global health network. A 1:1 propensity score matching (PSM) was utilized across 81 clinical covariates. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to assess long-term outcomes, including infectious complications, dialysis access revisions, and mortality.

RESULTS

Following PSM, 456 matched pairs (N = 912) of ESRD patients on dialysis were identified. There were no significant differences between the S-ICD and TV-ICD cohorts regarding the composite outcome of sepsis, bacteremia, or transvenous lead extraction (53.5% vs. 55.1%; p = 0.268). All-cause mortality (58.7% vs. 60.4%; p = 0.747) and hospitalization rates (87.9% vs. 85.4%; p = 0.874) were also similar between the groups. However, S-ICD was associated with higher rates of composite open and endovascular dialysis access revision (39.1% vs. 25.8%; p = 0.001), percutaneous dialysis access intervention (p = 0.002), and dialysis access surgery (p = 0.021).

CONCLUSION

S-ICD and TV-ICD demonstrated similar rates of infectious complications, hospitalization, and all-cause mortality in ESRD patients. S-ICD implantation was associated with higher rates of dialysis access revisions and interventions. Device selection should remain individualized, guided by anatomy, access planning, and clinical context.