A Practical Guide to Ultrasound-guided Venous Access During Implantation of Pacemakers and Defibrillators

Figures

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  Figure 1:. Fluoroscopic evaluation of venous anatomy pertinent to cardiac implantable electronic device implant. Venogram performed with a contrast injection via the left brachiocephalic vein. The locations of the left subclavian, axillary, and cephalic veins are labeled. The approximate location of the left axillary artery is marked by a red dashed line.

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  Figure 2:. Procedure for ultrasound (US)-guided access to the axillary vein. Step 1: Locate anatomic landmarks and perform percutaneous US imaging of the axillary vein. The locations of major anatomic landmarks are labeled in A. The location of the clavicle is marked with a red dashed line, and the location of the deltopectoral groove is marked with a black dashed line. The US probe is placed perpendicular to the skin. The US probe allows for the percutaneous visualization of the left axillary vein (V) and the left axillary artery (A), as shown in B. Pressing on the skin with the probe can help distinguish between a vein and artery, as gentle pressure will compress the vein but not the artery. The course of the axillary vein can thus be traced from the clavicle to the deltopectoral groove. The location of the axillary vein can be marked on the skin to guide the incision (A). Step 2: Make an incision at the marked location of the axillary vein and create the device pocket. The marked location of the axillary vein, as determined with percutaneous US (C), is the guide for the incision. The lateral end of the incision should be ≥1.5 from the target segment of the vein to ensure that…

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  Figure 3:. Fluoroscopic view of the point at which the axillary vein is entered using ultrasound (US) guidance. The point at which the tip of a 21-gauge needle was advanced through the anterior wall of the axillary vein with direct US is marked with an arrow. The location of the 0.018-in wire, which was passed through the needle and advanced to the level of the inferior vena cava, is also marked with an arrow.