Anatomical comparison of venous access options during cardiovascular electronic device implantation

doi:10.3969/j.issn.1674-8115.2026.09.015

Abstract

Abstract:

Cardiovascular implantable electronic devices (CIEDs) serve as crucial tools for the treatment and prevention of arrhythmia-related diseases, and related technologies are currently developing rapidly. Common access routes for clinical CIED implantation include subclavian vein, cephalic vein, and axillary vein. The selection of surgical access routes necessitates a comprehensive evaluation of venous anatomical characteristics, the complexity of the puncture procedure, and the long-term safety and efficacy of the device. In clinical practice, surgeons should pay particular attention to the choice of venous access and its association with puncture success rates and potential complications. In addition, the application of imaging guidance techniques such as X-ray and ultrasound enables surgeons to identify the course of the veins and their adjacent structures, reduce the risk of puncture-related complications, and further improve the surgical success rates. This article, based on the anatomical features of the veins and clinical experience, summarizes common anatomical variations and associated risks of the three veins, as well as new imaging-guided techniques. It also provides anatomical references for clinical CIED implantation.

Key words: vein puncture, cardiovascular implantable electronic device (CIED), applied anatomy, axillary vein

CLC Number:

R541.7

Fan Yichen, Zhuang Ruoxi, Qiu Zhaohui, Han Dan, Li Yan. Anatomical comparison of venous access options during cardiovascular electronic device implantation[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2026,(9): 1299-1306.

Figures/Tables 5

TrendMD

References 38

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Parameter	SVP	CVC	AVP
Parameter	SVP	CVC	X-ray fluoroscopy	Ultrasound guidance
Surface landmark	Junction of the clavicle and R1	Deltoid-pectoralis groove	No distinct surface landmark, difficult to localize
Depth	Deep; penetration of the subclavius muscle and fascia required	Superficial, course within the subcutaneous superficial fascia	Moderate, located beneath the deep fascia
Diameter	Large, suitable for multiple-lead implantation	Small	Large, suitable for multiple-lead implantation
Anatomical variation	Rare	Frequent	Frequent
Trajectory	Straight, easy lead advancement to the heart	Tortuous, via the cephalic-subclavian vein angle	Straight, similar to the subclavian vein
Adjacent structure
Artery and nerve	Adjacent to the subclavian artery and brachial plexus; puncture errors frequently observed	No major vessels or nerves in proximity	Adjacent to the axillary artery and brachial plexus
Pleura	Extremely close	Distant	Distant
Passage through costoclavicular space	Yes	No	No
Procedural difficulty	Moderate	Simple; surgical training required	Relatively high	Moderate; ultrasound equipment training required
Success rate	High (>95%)	Lower (~80%)	High (>95%)
Procedure time	Short	Longer, cephalic vein cutdown required	Moderate	Short, reduced number of attempts
Complication risk
Pneumothorax	High	No risk	Low
Subclavian crush syndrome	High	Very low	Low
Others	Risk of inadvertent arterial puncture, thoracic duct injury, and brachial plexus injury	Low risk of inadvertent puncture, risks of phlebitis and thrombosis	Risk of inadvertent arterial puncture and brachial plexus injury	Very low risk of inadvertent puncture
Risk related to imaging
Radiation exposure	‒	‒	High	Low
Iodinated contrast medium	‒	‒	Required; potential nephrotoxicity	Not required

Parameter	SVP	CVC	AVP
Parameter	SVP	CVC	X-ray fluoroscopy	Ultrasound guidance
Surface landmark	Junction of the clavicle and R1	Deltoid-pectoralis groove	No distinct surface landmark, difficult to localize
Depth	Deep; penetration of the subclavius muscle and fascia required	Superficial, course within the subcutaneous superficial fascia	Moderate, located beneath the deep fascia
Diameter	Large, suitable for multiple-lead implantation	Small	Large, suitable for multiple-lead implantation
Anatomical variation	Rare	Frequent	Frequent
Trajectory	Straight, easy lead advancement to the heart	Tortuous, via the cephalic-subclavian vein angle	Straight, similar to the subclavian vein
Adjacent structure
Artery and nerve	Adjacent to the subclavian artery and brachial plexus; puncture errors frequently observed	No major vessels or nerves in proximity	Adjacent to the axillary artery and brachial plexus
Pleura	Extremely close	Distant	Distant
Passage through costoclavicular space	Yes	No	No
Procedural difficulty	Moderate	Simple; surgical training required	Relatively high	Moderate; ultrasound equipment training required
Success rate	High (>95%)	Lower (~80%)	High (>95%)
Procedure time	Short	Longer, cephalic vein cutdown required	Moderate	Short, reduced number of attempts
Complication risk
Pneumothorax	High	No risk	Low
Subclavian crush syndrome	High	Very low	Low
Others	Risk of inadvertent arterial puncture, thoracic duct injury, and brachial plexus injury	Low risk of inadvertent puncture, risks of phlebitis and thrombosis	Risk of inadvertent arterial puncture and brachial plexus injury	Very low risk of inadvertent puncture
Risk related to imaging
Radiation exposure	‒	‒	High	Low
Iodinated contrast medium	‒	‒	Required; potential nephrotoxicity	Not required