Feasibility and accuracy of pre-procedure imaging of the proximal cephalic vein by duplex ultrasonography in pacemaker and defibrillator implantation

Background: Failure of the cephalic venous approach in pacemaker and defibrillator implantation is always due to the small size and difficulty in isolation of the cephalic vein. We propose that pre-procedure imaging of the proximal cephalic vein is valuable to achieve successful access of cephalic vein. However, the feasibility and accuracy of duplex ultra-sonographic imaging of the proximal cephalic vein are unknown. Methods: The study enrolled 30 consecutive patients who underwent new implantation of permanent pacemakers or defibrillators at our institute. An ultrasound probe scanned along the plane 2 cm beneath the inferior margin of the clavicle to locate the cephalic vein before device implantation. If the vein was well visualized, the venous diameter and the vertical depth were measured. The corresponding surface location of the vein on the chest wall was also identified and recorded by duplex ultrasonography. The echo-derived vertical depths and vascular findings were compared with those measured during surgery. Results: All proximal cephalic veins were well visualized in the infraclavicular region by duplex ultrasonography. They were compressible, patent in color Doppler ultrasound imaging, and displayed phasic change of Doppler signal during respiration, indicating patency in all study veins. The average diameter of the target cephalic vein was 7.7 +/- 1.6 mm (range, 5.0-11.1 mm). The echo-derived vertical depth of the proximal cephalic veins was highly correlated with the depth measured during surgery (28.4 +/- 5.5 vs. 28.4 +/- 5.6 mm, r = 0.93, P < 0.0001). All target cephalic veins were isolated after exploration via the estimated surface location of the chest wall by pre-procedure duplex ultrasonography. Seven (23%) of the studied patients did not have their cephalic vein cannulated successfully. Conclusion: The target proximal cephalic vein in pacemaker and defibrillator implantation can be precisely imaged and localized by duplex ultrasonography. Although further studies are needed, our findings pave a way to further study and clarify the implantation problems of cephalic vein approach.