• Theofilos M Kolettis, Dimitrios N Lysitsas, Dimitrios Apostolidis, Giannis G Baltogiannis, Eleni Sourla, and Lampros K Michalis.
• Department of Cardiology, University of Ioannina, Ioannina, Greece. thkolet@cc.uoi.gr
• Europace. 2010 Sep 1;12(9):1282-5.

AimsWe improved the cut-down approach aiming at minimizing the subclavian/axillary vein puncture during implantation of permanent pacemaker leads.Methods And ResultsWe incorporated previously reported refinements of the cut-down approach, i.e. the use of a hydrophilic guidewire when direct lead insertion failed and cannulation of retro-pectoral veins in cases of insufficient calliper of the cephalic vein. In addition, we introduced two further techniques, namely the simultaneous use of two guidewires and the use of stiff angiography guidewires. The efficacy of this integrated 'no-puncture' strategy was assessed in the first consecutive 200 patients and was compared with the 'standard' approach in an equal number of consecutive preceding implantations. Puncture was required more often (P < 0.0001) in the 'standard'-approach group (40/200; 20.0%). The 'no-puncture' policy was successful in 192/200 (96%) of implantations over a course of 40 months with absence of major complications. This was due to more frequent (P < 0.0001) use of hydrophilic guidewires (49.0% vs. 9.5% of cases), as well as due to cannulation of retro-pectoral veins (3.5%), use of a second guidewire (16.0%) and use of stiff guidewires (7.0%).ConclusionThe improved cut-down approach obviates subclavian/axillary puncture in the vast majority of cases and improves the safety of pacemaker implantation.

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