Heart rhythm O2 · 2026
Ultrasound-guided axillary access outperforms subclavian puncture for cardiac implantable electronic device implantation: A network meta-analysis of 130,831 patients.
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Almeida Maria Eduarda Marquez, Ribeiro Isabella Rodrigues, Martins Charles Karel, Barbosa Gabriel Alves, Miranda Maria Clara, da Silva Menezes Júnior Antônio
Аннотация
BACKGROUND: The optimal venous access route for cardiac implantable electronic device implantation remains debated.
OBJECTIVE: We compared the efficacy and safety of subclavian vein puncture (SVP), cephalic vein cutdown (CVP), and axillary vein puncture guided by fluoroscopy (FL-AVP) and ultrasound (US-AVP).
METHODS: A systematic search of PubMed, Embase, Cochrane Central, and Web of Science (until September 24, 2025) identified randomized and observational studies comparing ≥2 venous access techniques for cardiac implantable electronic device implantation in adults. A frequentist random-effects network meta-analysis estimated odds ratios (ORs) or standardized mean differences with 95% confidence intervals. Heterogeneity, network consistency, and ranking probabilities were assessed using P scores.
RESULTS: Of the 4316 records screened, 25 studies (130,831 patients) were included. CVP was significantly less successful than FL-AVP (OR 0.18), SVP (OR 0.14), and US-AVP (OR 0.17). SVP carried a higher risk of overall complications than US-AVP (OR 2.21). Procedure time was longer for CVP than for FL-AVP or US-AVP. FL-AVP entailed greater fluoroscopy time and radiation exposure than US-AVP. Pneumothorax occurred less frequently with CVP and FL-AVP than with SVP, whereas lead dislodgement and pericardial effusion were less common with CVP than with SVP. Network ranking favored SVP for procedural success and US-AVP for safety and radiation reduction.
CONCLUSION: Axillary (ultrasound- or fluoroscopy-guided) and cephalic approaches outperform subclavian puncture in risk-benefit. US-AVP is considered the first-line technique, FL-AVP is a valid alternative when ultrasound is unavailable, and CVP is preferred for selected anatomies. In contrast, SVP should be reserved for bailout cases.PROSPERO CRD420251017329.
OBJECTIVE: We compared the efficacy and safety of subclavian vein puncture (SVP), cephalic vein cutdown (CVP), and axillary vein puncture guided by fluoroscopy (FL-AVP) and ultrasound (US-AVP).
METHODS: A systematic search of PubMed, Embase, Cochrane Central, and Web of Science (until September 24, 2025) identified randomized and observational studies comparing ≥2 venous access techniques for cardiac implantable electronic device implantation in adults. A frequentist random-effects network meta-analysis estimated odds ratios (ORs) or standardized mean differences with 95% confidence intervals. Heterogeneity, network consistency, and ranking probabilities were assessed using P scores.
RESULTS: Of the 4316 records screened, 25 studies (130,831 patients) were included. CVP was significantly less successful than FL-AVP (OR 0.18), SVP (OR 0.14), and US-AVP (OR 0.17). SVP carried a higher risk of overall complications than US-AVP (OR 2.21). Procedure time was longer for CVP than for FL-AVP or US-AVP. FL-AVP entailed greater fluoroscopy time and radiation exposure than US-AVP. Pneumothorax occurred less frequently with CVP and FL-AVP than with SVP, whereas lead dislodgement and pericardial effusion were less common with CVP than with SVP. Network ranking favored SVP for procedural success and US-AVP for safety and radiation reduction.
CONCLUSION: Axillary (ultrasound- or fluoroscopy-guided) and cephalic approaches outperform subclavian puncture in risk-benefit. US-AVP is considered the first-line technique, FL-AVP is a valid alternative when ultrasound is unavailable, and CVP is preferred for selected anatomies. In contrast, SVP should be reserved for bailout cases.PROSPERO CRD420251017329.