Axillary vein access with or without venography: is this the dilemma in the ultrasounds era?

We read with great interest the article by Squara et al.1 ‘Self-taught axillary vein access without venography for pacemaker implantation: prospective randomized comparison with the cephalic vein access’. The main findings of this study confirm that the axillary ‘blinded’ access (without venography) is of fast implementation even among untrained operators. The axillary access is indeed faster than the cephalic vein approach in terms of both venous access time and whole procedure duration. This is true if we consider that the cephalic approach is a surgical technique which foresees vein preparation, cut, as well as the insertion of the electrocatheter or the guidewire. This procedure is particularly time-consuming when performed in obese patients, where the subcutaneous fat component is abundant. However, it remains the most preferred approach among operators.2 On the contrary, direct axillary vein puncture allows the operator to shorten the first part of the implantation procedure. We fully agree with the authors that the latter technique is safe and effective, and, hence, it could replace cephalic or subclavian approach, even in the context of three-chamber device implantations (not represented in the study by Squara et al.1). However, we were not surprised by the number of complications related to this procedure, namely intense vasovagal reactions and brachial plexus transient palsy (respectively 2 and 2 in the axillary group). The authors specified that mean duration of the axillary cannulation was shorter when compared with surgical preparation of the cephalic vein (5.7 min vs. 12.2 min, P < 0.001); however, they did not specify the number of failed attempts for guidewire insertion in the axillary vein. Although the technique contemplates visualization of the first rib with fluorography, it remains a blinded approach because the vein is not displayed at all. This aspect leads to an inevitable increase in the number of unsuccessful attempts before centring the vessel. This could explain the complications reported by the authors. Such blinded approach is also associated with a slight increase in the risk of pneumothorax or haemothorax. The use of venography in these cases is only partially helpful, because the visualization of vein trajectory occurs before and not during the puncture. Moreover, venography does not provide any information on vessel depth. This is why we firmly believe that axillary vein puncture should be always performed under ultrasound guidance. By directly visualizing the vessel during the puncture, the operator can follow the progress of the needle onto the subcutaneous tissue, check the depth of the vein, avoid an accidental puncture of the artery, thus minimizing the number of unsuccessful attempts and complications due to stimulation or injury of the brachial nerve. Last but not least, the operator can inject local anaesthetic directly into the region where the needle must be advanced, thus securing optimal anaesthesia. Hence, ultrasound-driven axillary vein puncture has proved to be effective and safe without increasing procedure time.3 In conclusion, when dealing with axillary puncture in the setting of cardiac implantable electronic devices implantation, the dilemma is no longer whether or not to perform the venography but to sensitize towards the systematic use of ultrasound. The latter may significantly contribute to improve the quality of care of our patients. Conflict of interest: none declared.