Thank you for the invitation. I'm not at Kentucky anymore. I'm now in Florida, but that's not that far. So I'm going to talk about Pneumothorax doing cardiac implantable electronic device implants. So it's an inner leak in the pleural cavity during venous access. And the incidence has been variable in literature, been reported between 0% and 4%. In a recent analysis of the NIA database that reflect patient hospitalized in the United States, the incidence was 1.3% out of about 3.7 million patients, so probably around 1% to 1% true incidence. The pneumothorax can be completely asymptomatic or can be life-threatening. So potential consequences is increased morbidity, length of stay, costs, and mortality with a node ratio of 1.5. In the United States, iatrogenic pneumothorax are hospital-acquired condition, meaning that CMS doesn't pay for it, so the hospital will have to pay for it. The clinical predictor of pneumothorax, an older age, female sex, COPD, low BMI, less than 25, and unusual anatomy. The procedural predictors during the implant, so I think the most important one, is the type of venous access. Succlavian has a much higher risk of pneumothorax than axillary or cephalic vein, obviously. And we'll go into detail here in a minute. Other include the number of leads. The more stick you do, the more likelihood you have to have pneumothorax. And some other possible one here are listed. So let's review the three type of venous access and their respective risk of pneumothorax. First cephalic vein, then, I'm sorry, first succlavian vein, then cephalic vein, then axillary vein, whether you use a fluoroscopic or ultrasound. So first, succlavian vein access. So the needle enters typically in the middle thread of the clavicle and is directed toward the sternal notch. So this is for, clearly, the venous access associated with the high risk of pneumothorax. And I'll show you more data in a second here. The major other disadvantage with this access is that you can get mechanical failure of the lead. It's the highest with this technique and the crush syndrome. Second access, the cephalic vein access. So this cephalic vein is here in the deltopectoral groove. You can see it, if I move my mouse, do you see it over there or you don't see it? No, you don't see it, okay. So you can see here with an arrow the cephalic vein on the left panel on the fluoroscopic view. And on the ultrasound view, you can see that the cephalic vein drains into the axillary vein. So this access technique has virtually no risk of pneumothorax, obviously because you're outside of the thorax, right? However, the disadvantages, one of the main disadvantages of the cephalic access is that the rate for the failure rate for implant is between eight and 35%. That's what is in the literature. It's pretty high. So obviously if you fail the cephalic, then you have to go to a more traditional and you have a risk of pneumothorax, especially that those pockets tends to be a bit more lateral. Other disadvantages of cephalic vein are a longer timing compared to axillary vein and if you do cut down more blood loss. So now let's talk about the axillary vein access, which has become very popular because it's a very vein that you can access in its course between the first rib and the second rib and it's a large vein. You can accommodate several veins. So there are several variants. You can use surface or more commonly fluoroscopic landmarks, what we call the blind technique because blind because you don't see the vein or you can decide you're gonna want to see the vein and you can either do ultrasound or venogram. There is other variant as whether you get access before or after creating the pocket. You can have a more medial or more lateral stick when you enter for the access. So let's talk about the three common variants with axillary vein. The x-ray, pure x-ray, x-ray with venogram or x-ray or ultrasound. So we created this image from a reconstructed CT. You can see where the needle stands on the first rib and you can see also on the side the second rib, the anterior first and second rib. And in blue you can see the trajectory of the axillary veins over the second rib then the first rib becoming after that the subclavian vein. Just above that you have the axillary vein. So if you go and stay on top of the first rib or even the second rib and you advance, there is no way you're gonna go into the thorax. And actually Dr. Bellot has a great paper where he described that. I think it was in 2006 in Hartford. Great description of the first rib, what we call the first rib approach. So you look on the x-ray, you can delineate your first rib. The middle border, the lateral border. You advance your needle. So your entry point could be at the middle of the first rib or a bit more, I do it personally a bit more lateral. You advance and if you hit the axillary vein and you weigh in, that's great. If you don't, most often you don't. So you hit the first rib and you get it on your way back. You stay always lower on the first rib. You start lower if you don't have a venogram and you work your way up because the vein being below the artery, you're gonna hit the vein first before the artery. So advantages of the x-ray. Well, it's a very simple technique. You don't need ultrasound, you don't need venogram, but there are some disadvantages. You can radiate your hand even though it's a little bit of radiation. Often you have to do several sticks. You start lower and you work your way up. You cannot assess the patency of the axillary vein of the subclavian or the SVC. And you cannot assess either the persistent left superior vena cava unless you get an access before you open your pocket and see that your wire is going the proper way. The superior left vena cava is not always an issue, but I think if you want to put an LV lead or an ICD, then it's a bit more difficult to do it with an SVC. So the technique with the x-ray and venogram is the same thing except that you're gonna visualize with your venogram where the axillary vein passes over the first strip, so you have a better target to go. So you have a more precise location of the vein if you do a venogram, and you can be sure that not only your axillary vein, but your subclavian and your SVC are patent. You can be sure that there is no personal SVC. As a disadvantage, you have always radiation on the hands of the operator, and you have the complication of the contrast, either anaphylaxis or kidney failure. So here are all the data that I found in the literature, series of 100 device or more. On the left column, you have all axillary vein access. On the right column, you have the subclavian. So all of them compare axillary versus subclavian, except the last three that were prospective study with the axillary only. So if you add all the axillary cases, there was about 1800 cases, and yet there was one pneumothorax so a very low incidence, 0.06. If you sum all the subclavian vein that were often the control group, you have 30 pneumothorax out of about 1600 patients. So 1.9% of pneumothorax. So I think this slide tells the story here. You can do it also with ultrasound. So here, this is an example that when we use ultrasound, you can do transverse access or longitudinal access. On this view, you recognize the artery on the left and the vein on the right, and you can recognize the vein. Either you can compress it with the ultrasound probe, or you can also recognize it because there are more respiratory variation. If the vein is, if the patient is dry, you're gonna see a very small vein that's very easy to collapsible. You can also do the same thing in the longitudinal view. To my opinion, it's a bit more difficult. And you can see here, we are pushing some saline in the image to get a better flow in the vein. So advantages of ultrasound. You can verify that the axillary vein is patent, that the well is well hydrated, there's no radiation, there is no risk of anaphylaxis or kidney failure. And if you have a patient that is very old where you can barely see the first root because it's very demineralized, or if you have a complex anatomy, I think that's the way to go so you can visualize your vein. Disadvantages of the ultrasound. You cannot access a more proximal subclavian or SVC occlusion if there was one. You cannot, of course, rule out the NL-persistent SVC. You need an ultrasound machine with some minimal eco-skills. And there is a workflow interference of wired probe. Also nowadays, they have now this new wireless probe that you can use. So here are the data that I found on ultrasound access. There is about 700 patient literature, one out of 738, so 0.48% of pneumothorax. So I think this slide is the most important slide for my talk. If you remember, one thing is this slide. If you do a subclavian access, you have about 2% literature of pneumothorax. If you do axillary, whether you do X-ray or ultrasound, it's extremely low. Virtually, there's almost no pneumothorax, 0.1%. And if you do the cephalic, it's gonna be somewhere in between, depending what's the failure rate of getting the cephalic. Other strategy to reduce pneumothorax, you can use a mitral puncture needle. Obviously, if you use a 21-gauge needle that's gonna be smaller than the standard 18-gauge needle, you're gonna be less traumatic. However, there's no data to support any difference. You can also increase the size of the targeted vein to engross the vein with either increased hydration with IV fluids before the procedure or during the venous puncture. You can elevate the legs, put a wedge under the legs. Thank you, Dr. Romey. You can do Valsalva maneuvers. You can also remove pillows or have the patient, if he's not asleep, shrug the shoulder back and forth to try to better expose the vein. And if you're working with a trainee, you have to be careful if it's a very high-risk patient to get pneumothorax. You can also use this trick in this patient. We have a left arm clot, so we could not do a venogram. So we went as a first rib and tried to go on the first rib and couldn't get access, so we put a GR4 catheter from the right femoral vein. And you can see that, in fact, the axillary vein was higher than what would normally be on the first rib, so it was easier to get it, you can see, on the second rib. There is a Japanese theory, actually, that published a couple of cases like this. So in conclusion, ladies and gentlemen, the pneumothorax during CID implants remains an important cause of morbidity and mortality. The access of the axillary vein with either X-ray or ultrasound have greatly reduced the occurrence of pneumothorax to almost being close to zero. And you can consider other factors to reduce pneumothorax, such as the proper hydration, fluid injection during access, legs elevation, microfunction needle, valsalva. Thank you for your attention. Thank you. We have time for one or two brief questions. I have a question, one comment and one question. We've seen, especially with fellowship program and training program, and we have different sizes of patients coming in. Unfortunately, the norm has become being overweight. And one comment about the axillary vein, which is our approach for the most part, when every once in a while you get somebody who's very fit, those scare me more, actually, because sometimes, after many, many cases of people who are overweight, you tend to be a bit more lateral, be more aggressive, and you might be tricked. You might be under the first rib instead of over the first rib. So, again, word of caution about the thin and fit. It's not always less risk compared to the overweight. One question about, we've been avid users of ultrasound for venous access in the groin for all our ablations. And actually, again, a lot of respect doing this with all the variation to the point that, quite frankly, I feel uncomfortable doing it, not because I don't know where the anatomy, but all the variation that you see. But I'm a bit uncomfortable with the sterility for devices still not the routine use. Any comments about what do you do to avoid any risk of infection when you use the ultrasound? Yeah, obviously, it's adding a piece of equipment, so I think there's concern. I think ultrasound probes that are wireless may be a way to go, so you have less risk of contamination if you do careful scrubbing. And to go to your point of obesity, I didn't put it here in the slide, but so obesity was protective against pneumothorax, actually, in one of the study that I mentioned before. I have one final comment. I think it's very important to know where the first rib is if you're gonna use it for guidance. And I've had seen several instances where they mistook the first rib and it was actually a posterior rib, and I'm sure right away they got a pneumothorax. Yeah, that's a great comment, thank you. Thanks, Claude. Thank you.

pneumothorax

cardiac implantable electronic device

CIED implants

clinical predictors

procedural predictors