Prospective study of axillary vein puncture with or without contrast venography for pacemaker and defibrillator lead implantation.

Axillary vein puncture may be used to implant pacemaker (PM) or cardioverter defibrillator leads, though usually requires venography. We prospectively compared punctures guided by venography versus a new radiological landmark. In 232 patients, the puncture was guided by injecting diluted contrast material via an ipsilateral peripheral vein (group A, n = 142), or without venography using the intersection of the lateral borders of the second and third rib as a radiological landmark, followed by contrast injection in case of failure (group B, n = 90). We implantated 1-3 leads per patient. In group A, implantation was successful in 135 patients (95%) and in group B in 55 patients (61%, P < 0.001 vs group A). Subsequent contrast injection allowed successful implantations in 34 of 35 patients, with an success rate of 97% for the overall study population of 224 patients. Venous access was achieved after a mean of 10.4 +/- 3.2 minutes of skin incision in group A versus 9.4 +/- 3.0 minutes in group B (ns). Pneumothorax occurred in two patients (1% overall). Thus non-contrast guided puncture using a new radiological landmark was successful in a majority of patients. This technique may be useful in absence of ipsilateral peripheral vein access, or presence of contrast allergy.