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Ultrasonographic predictors of unsuccessful cephalic vein approach during pacemaker or defibrillator lead
Jan-Yow Chen1, Kuan-Cheng Chang, Kuo-Hung Lin
1Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan.
Insights
Small cephalic vein diameter (< or = 2.2 mm) and tortuosity predict endocardial lead implantation failure. Ultrasound can identify these risks, and hydrophilic guidewires can improve success rates in tortuous veins.
Area of Science:
- Cardiovascular Interventions
- Medical Imaging
- Vascular Anatomy
Background:
- The cephalic vein approach is common for endocardial lead implantation but has a high failure rate.
- Anatomic variations are suspected causes of failure but are not well-defined.
Purpose of the Study:
- To evaluate the role of cephalic vein characteristics in endocardial lead implantation success.
- To identify ultrasonographic predictors of implantation failure.
Main Methods:
- Color Doppler ultrasonography assessed venous diameter, depth, flow, and morphology in 82 patients.
- Comparisons were made between successful and failed lead implantations.
Main Results:
- Implantation failed in 17% of patients (isolation, cannulation, or guidewire crossing issues).
- Cephalic vein diameter < or = 2.2 mm was the sole independent predictor of failure.
- Tortuosity was present in 10 patients, with significantly higher guidewire crossing failure (7/10).
Conclusions:
- Color Doppler imaging effectively identifies cephalic vein anatomy relevant to lead implantation.
- Small venous diameter predicts cephalic vein approach failure.
- Tortuous veins increase guidewire crossing failure, often manageable with hydrophilic guidewires.
Background:
The cephalic vein approach is a preferred route for endocardial lead implantation; however, it is associated with a significant failure rate. Anatomic abnormalities likely play an important role, but specific features have not been well characterized.
Methods:
Color Doppler ultrasonography was performed in 82 consecutive patients prior to endocardial lead implantation. Venous diameter, depth, flow velocity, and morphology were evaluated and comparisons made between the successful and failed implantations at various stages of the procedure.
Results:
Endocardial lead implantation was unsuccessful in 14 patients (17%), with eight patients of venous isolation failure, 4 patients of cannulation failure, and 2 patients of guidewire crossing failure. Venous diameter was found to be the only independent predictor for isolation and implantation failure. The best cutoff value of cephalic venous diameter to predict unsuccessful cephalic venous approach was < or = 2.2 mm. In total, there were 10 patients with extensive cephalic vein tortuosity. In seven of these 10 patients, the incidence of standard guidewire crossing failure was significantly higher than that without a tortuous cephalic vein (7/10 vs 6/60, P < 0.001). After switching to a hydrophilic guidewire, crossing and navigation were successful in five of the seven patients.
Conclusions:
Color Doppler imaging is useful to identify cephalic vein characteristics. A small venous diameter is the ultrasonographic predictor for failure of cephalic vein approach. A tortuous venous morphology is associated with a high incidence of guidewire crossing failure, which can be mostly overcome by using a hydrophilic guidewire.
