Axillary vein access using ultrasound guidance, Venography or Cephalic Cutdown—What is the optimal access technique for insertion of pacing leads?

We reviewed the different approaches used for central vein access during insertion of cardiac implantable electronic devices. The benefits and hazards of each approach (cephalic vein cutdown, axillary vein cannulation using venography and ultrasound) are discussed. Each approach has its advantages and hazards that need to be considered for the individual patient and balanced against the skills of the operator. The benefits of ultrasound guided venous access in reducing radiation exposure to the patient and implanter, avoiding the need for angiographic contrast and in minimizing the risk of pneumothorax and inadvertent arterial puncture are highlighted. Trainees should be taught each approach to deal with patient variability. Ultrasound guidance should be considered as a mainstream option for most patients. We review the techniques used to implant pacemaker leads. Ultrasound guided axillary vein access was shown to have a higher acute success rate than cephalic cutdown, does not require radiation and had the same safety profile as the cephalic approach. Ultrasound guided axillary vein access or a cephalic vein approach should be favoured as the first line options for implanting pacing leads and should be mandated training for future implanters.