Axillary vein spasm during cardiac implantable electronic device implantation

The technique of axillary vein (AV) or subclavian vein (SV) puncture has become an important alternative to cephalic vein (CV) cutdown as an approach allowing cardiac lead introduction into the venous system during cardiac implantable electronic device (CIED) implantation procedures. Irrespective of the technique used, the injury associated with lead insertion may induce a reflex venous spasm that can even cause total venous obstruction. In order to assess the incidence of AV spasm during AV puncture, we analysed a total of 735 (382 in females and 353 in males; mean age 75 ± 11 years) de novo CIED implantation procedures involving transvenous lead insertion conducted between January 2014 and December 2015. In 337 patients the leads were introduced via AV puncture only, in 66 patients AV puncture was used in combination with CV cutdown, together yielding a total of 403 procedures (55% of all de novo CIED implantation procedures; mean patient age 72 ± 14 years), out of which we observed 12 cases (mean patient age 57 ± 25 years) of AV spasm (3%). We evaluated only the procedures with unambiguous fluoroscopy images recorded during AV puncture: complete blockage of contrast medium flow through the AV, with preserved flow through the CV or collateral vessels, followed by eventually resumed flow of contrast via the AV. The contrast-enhanced movements of AV walls showed the spasm propagating both proximally and distally along the vessel, while the subsequent vessel wall relaxation occurred along the entire spasm-affected venous segment simultaneously. An AV spasm induced by AV puncture during CIED implantation is a rare phenomenon; however, if severe, it may significantly affect the course of the procedure.