Ultrasonographic Predictors of Unsuccessful Cephalic Vein Approach During Pacemaker or Defibrillator Lead Implantation

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.