Abstract
BACKGROUND: The axillary vein approach has emerged as a promising alternative to subclavian venous access for pacemaker implantation, offering potential advantages including reduced infection risk and enhanced procedural success. However, standardized protocols for fluoroscopy-guided axillary vein puncture remain undefined. OBJECTIVES: This study aimed to (1) evaluate the feasibility of a simplified fluoroscopic technique for axillary vein puncture and (2) establish anatomical and clinical predictors of procedural success. METHODS: In this retrospective cohort study, 178 consecutive patients undergoing pacemaker implantation at Shanghai Tongji Hospital (January 2022-December 2023) were stratified by puncture technique: right anterior oblique (RAO) 30°, Caudal 35° (C-arm angled toward feet), and vein-guided fluoroscopy. Demographics (age, sex), comorbidities (chronic obstructive pulmonary disease (COPD), spinal disorders), smoking status, and radiographic parameters (subclavian fat thickness, clavicle-first rib angle) were analyzed. RESULTS: Axillary vein puncture was successful in 169/178 patients (94.9%) without venography. First-attempt success rates were 75.8% (135/178) for RAO 30° and 79.1% (34/43) for Caudal 35°. Key predictors of success included: Sex-specific anatomy, BMI threshold and Clavicular angx les. There was a significant difference in smoking status, subclavian fat thickness 2 cm below the collarbone between males and females (P < 0.001).ROC analysis identified BMI ≥ 23.84 kg/m² as optimal for success (AUC = 0.64, 95% CI: 0.48-0.83).Frontal clavicle-first rib angle independently predicted RAO 30° success (P = 0.012, OR = 1.08, 95% CI: 1.02-1.15), while RAO clavicle-first rib angle correlated with Caudal 35° success (P = 0.031, OR = 1.05, 95% CI: 1.01-1.09). In this study, the cumulative incidence of procedure-related complications was 1.69%. Severe complications such as pneumothorax or lead dislodgement were not observed, highlighting the safety profile of the intervention. CONCLUSIONS: Successful fluoroscopy-guided axillary vein puncture depends critically on patient-specific anatomical factors, including sex, BMI, clavicle-first rib spatial relationships, and smoking status. Our standardized protocol achieved high success rates (94.9%) without ultrasound assistance, highlighting its utility in resource-limited settings.