Outcome of Ultrasound-Guided Versus Fluoroscopy-Guided Versus Cephalic Cutdown Permanent Pacemaker Implantation

INTRODUCTION: The universal standard practice for central venous access during permanent pacemaker (PPM) implantation is fluoroscopy with venogram. Ultrasound-guided access is increasingly encouraged to minimize radiation, contrast load, and inadvertent injury to surrounding structures. However, its complication profile in PPM implantation remains uncertain. This study compared complications and radiation exposure across ultrasound-guided, fluoroscopy-guided, and cephalic vein cutdown approaches. METHODS: A retrospective cross-sectional study of 202 consecutive patients undergoing elective or urgent PPM implantation by experienced operators at a single center (August 2021-August 2022) was performed. Access-related complications, fluoroscopy time, and radiation dose were analyzed. Complications were predefined as one or more of the following events: arterial puncture, haematoma, pneumothorax, lead or device failure, or procedure failure. RESULTS: Among the cohort, 56/202 (28%) underwent ultrasound-guided access, 114/202 (56%) fluoroscopy-guided access, and 32/202 (16%) cephalic cutdown. Complication rates were 5.4% (3/56) for ultrasound-guided, 9.6% (11/114) for fluoroscopy-guided, and 9.4% (3/32) for cephalic cutdown (χ² test, p = 0.62). Radiation dose differed significantly between groups (Kruskal-Wallis test, p < 0.001), with the lowest median (IQR) exposure in the cephalic cutdown group at 10.1 mGy (6.7-17.0), followed by ultrasound-guided access at 13.4 mGy (9.2-23.1) and fluoroscopy-guided procedures at 19.2 mGy (12.2-31.0). CONCLUSION: Ultrasound-guided access was associated with the lowest observed complication rate, although this was not statistically significant, likely reflecting limited sample size. Radiation exposure varied significantly by access method, with ultrasound guidance offering an intermediate profile between cephalic cutdown and fluoroscopy. These findings support the safety of ultrasound-guided access and highlight the need for larger studies to confirm its role in reducing complications and radiation burden in PPM implantation.