A call for safety during electrophysiological procedures: US in, why not US out?

We read with great interest the paper by Sobolev et al.1 entitled ‘Ultrasound-guided cannulation of the femoral vein in electrophysiological procedures: a systematic review and meta-analysis’. Like all meta-analyses, it does not provide certainties but may set the stage for launching randomized trials on this important topic. Vascular damages during electrophysiological (EP) procedures are critical events which may have a substantial impact on patients prognosis, thus increasing their anxiety and fear towards the procedure. Furthermore, when compared with other complications (i.e. atrioventricular block, embolic events, cardiac tamponade), the vascular ones seem to be relatively frequent, being recently reported in similar or even higher percentages in recent studies. These data are not surprising if we consider that over the last few years, patients on anticoagulant therapy have become a very represented population in the setting of EP procedures. Moreover, many of these procedures are complex and require the introduction of several wide sheaths often in the same vein, or—alternatively—a retrograde approach through the femoral artery when the ipsilateral vein is already cannulated.2 However, the major determinant of vascular complications is still represented by vein cannulation. Since femoral vein cannulation has been performed palpation of external anatomical landmarks has been usually employed to guide the insertion of the needle into the vessel. However, this procedure is highly dependent on operator’s skills and patient anatomy, and this aspect mostly contributes to scarce success and undesirable complications. Over the last 10 years, the increasing use of an ultrasound-guided approach in central veins cannulation has dramatically improved the success rates, while reducing procedure time and complications. Although this is a well-established and safe approach employed by most medical specialists (i.e. anaesthesiologists, interventional radiologists, and nephrologists), and even recommended in international guidelines,3 interventional cardiologists seem to be still far from having employed this approach in their routine practice. In the present study by Sobolev et al.,1 the authors report that ultrasound guidance for femoral vein cannulation in the setting of EP procedures was associated with 60% reduction in the likelihood of major vascular complications and a 66% reduction in minor vascular complications. We do believe success rates could be even higher when the operator is adequately trained and becomes confident with the technique. Such an approach should be the standard of care in EP laboratories, in high-volume centres as well as in low-volume centres where operators may be less skilled in the cannulation procedure. One of the most useful innovations in electrophysiology over the last few years is the intra cardiac ultrasound. Its introduction during complex procedures or in unfavourable settings has definitely brought more security and confidence to the operators thanks to the direct visualization of the anatomy.4 The community of electrophysiologists has welcomed this innovation, willingly accepting the increased cost of this imaging-based approach. Surprisingly, this is not yet the case with US-guided femoral cannulation, which is a highly cost-effective procedure requiring a very short learning curve.5 Here comes the question: ‘US IN…WHY NOT US OUT??’. In other words, we have been persuaded about the advantages of ultrasounds into the body of our patients (US IN), so why should not we benefit from using ultrasounds from outside (US OUT). This allows to carefully monitor the procedure from the very early stages without any risk of leaving our patients exposed to concrete hazards of vascular complications. Increased awareness about an US-guided approach in EP procedures may substantially increase the safety of our patients and improve the quality of care. Conflict of interest: none declared.