Ultrasound-guided axillary access outperforms subclavian puncture for CIED implantation: a network meta-analysis of 130,831 patients
A Menezes Junior, M E Marquez Almeida, I R Ribeiro, C K M Santos, G A Barbosa, M C R MirandaAbstract
Background/Introduction
The optimal venous access route for cardiac implantable electronic device (CIED) implantation remains debated due to trade-offs between success, complications, and radiation.
Purpose
The purpose of this study was to compare the efficacy and safety of various venous access techniques, including subclavian vein puncture (SVP), cephalic vein cutdown (CVC), and axillary vein puncture guided by fluoroscopy (FL-AVP) or ultrasound (US-AVP).
Methods
We systematically searched PubMed, Embase, Cochrane Central, and Web of Science to 24 September 2025 for randomized and observational studies comparing ≥2 access techniques in adults. A frequentist random-effects network meta-analysis estimated odds ratios (ORs) or standardized mean differences (SMDs) with 95% confidence intervals. Heterogeneity, local/global inconsistency, and ranking probabilities were assessed using P-scores.
Results
Out of 4,316 records, 25 studies (n = 130,831) met inclusion criteria. CVC was significantly less successful than FL-AVP (OR 0.18), SVP (0.14), and US-AVP (0.17). SVP carried a higher risk of overall complications than US-AVP (OR 2.21). Procedure time was longer for CVC than for FL-AVP or US-AVP. FL-AVP entailed greater fluoroscopy time and radiation exposure than US-AVP. Pneumothorax occurred less frequently with CVC and FL-AVP than with SVP, while lead dislodgement and pericardial effusion were less common with CVC than with SVP. Network ranking favored SVP for procedural success and US-AVP for safety and radiation reduction; FL-AVP ranked intermediate, as shown in Figure 1 and 2.
Conclusion(s)
Considering efficacy, complications, and radiation, axillary approaches (US- or FL-guided) and the cephalic approach outperform subclavian puncture on overall risk–benefit. US-AVP could be considered FL-AVP a possible valid alternative when ultrasound is unavailable, and CVC suitable for selected anatomies. SVP could be reserved for bailout situations.Network Graph for Primary EndpointsNetwork Graph for Secondary Endpoints