Ultrasound-guided axillary access outperforms subclavian puncture for cardiac implantable electronic device implantation: A network meta-analysis of 130,831 patients

The optimal venous access route for cardiac implantable electronic device implantation remains debated.

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).

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.

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.

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.