Background: Upgrade of cardiac rhythm devices requires the operator to obtain additional venous access to accommodate additional pacing or defibrillator leads. This is conventionally done by either the axillary or subclavian venous route using fluoroscopically guided puncture. An alternative technique is to use venotomy of the cephalic vein under direct vision but this is usually ignored to due to concerns about venous stenoses around existing lead entry points.
Aim: To establish whether the cephalic vein may routinely be used for upgrade of existing CRM devices.
Methods: Personnel, procedural and complication data were extracted from records of all CRM upgrade procedures at St Georges Hospital, London and Royal Surrey County Hospital, Guildford between 1 October 2009 and 30 September 2017. Operators were encouraged to use cephalic access.
Results: Three-hundred-and-twenty-three device upgrade procedures were attempted by 21 primary operators, who undertook between one and 163 procedures each. Four procedures failed to deploy any additional leads and in 72 cases no data was available on the access route used. Of the remainder, leads were added as shown in Figure 1. In 25 procedures (10%), the cephalic was known to have been previously used and only non-cephalic access attempted for additional leads. In 89 procedures (40% of those with no prior use of the cephalic vein), further leads were successfully added via the cephalic vein.
Discussion: In the absence of documented previous use of a cephalic vein, in most procedures it is possible to add further leads via the cephalic route. This is widely accepted to be the lowest risk venous access route used in CRM procedures and should not be discounted due to the presence of existing leads.