What is the incidence and management of subclavian artery injury during pacemaker device placement using ultrasound-guided access to the subclavian vein?

From the Guidelines

Subclavian artery injury during pacemaker placement using ultrasound-guided subclavian vein access is rare, with an incidence of less than 0.5%. When using proper ultrasound guidance technique, the risk is significantly reduced compared to traditional landmark-based approaches 1. Management of subclavian artery injury depends on severity but typically includes:

• Immediate recognition
• Compression
• Consultation with vascular surgery For minor injuries with small hematomas, manual compression for 10-15 minutes is often sufficient. More significant injuries may require:
• Prolonged compression (30+ minutes)
• Reversal of anticoagulation if applicable
• Placement of a vascular closure device or surgical repair Severe injuries with active extravasation or expanding hematomas necessitate immediate vascular surgery consultation and possible endovascular stenting or open surgical repair. Prevention is key and involves:
• Proper ultrasound technique with clear visualization of the needle path
• Maintaining the needle in-plane with the ultrasound beam
• Confirming venous access with color Doppler prior to dilation
• Using a micropuncture kit for initial access Operators should be prepared for potential complications with immediate access to compression bandages, reversal agents for anticoagulants, and an established protocol for vascular surgery consultation 1. The use of ultrasound guidance has been shown to reduce the risk of complications, including arterial puncture and hematoma formation, and is recommended for central venous catheter placement, including subclavian vein access 1.

From the Research

Incidence of Subclavian Artery Injury

• The incidence of subclavian artery injury during pacemaker device placement is not explicitly stated in the provided studies, but it is considered a rare complication 2.
• A study on ultrasound-guided axillary/subclavian venous approaches for pacemaker and defibrillator lead implantation did not report any cases of subclavian artery injury 3.
• Another study on real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients reported a lower incidence of complications, including artery puncture, in the ultrasound group 4.

Management of Subclavian Artery Injury

• If subclavian artery injury is suspected, it can be managed using a collagen-based closure device, which has been shown to be a simple and successful alternative therapy when surgical direct vascular repair is not possible or not available 2.
• Endovascular graft repair is another option for treating penetrating subclavian artery injuries, which has been shown to be effective in a small series of patients 5.
• Ultrasound guidance can help reduce the risk of complications during central venous catheter placement, including subclavian artery injury, and can facilitate the adoption of ultrasound guidance for implanting leads for cardiac rhythm management devices 6.

Use of Ultrasound-Guided Access

• Ultrasound-guided access to the subclavian vein has been shown to be a safe and effective technique for pacemaker and defibrillator lead implantation, with a high success rate and low incidence of complications 3, 6, 4.
• Real-time ultrasound-guided subclavian vein cannulation has been compared to the landmark method in critical care patients, and has been shown to be superior in terms of success rate, access time, and incidence of complications 4.