Response to: Do not yet abandon cephalic vein access for
multiple leads in ICD implantation
Chirag R. Barbhaiya, MD
Osama Niazi, MD
Lior Jankelson, MD, PhD
Scott Bernstein, MD
David Park, MD, PhD
Douglas Holmes, MD
Anthony Aizer, MD, MSc, FHRS
Larry A. Chinitz, MD, FHRS
Leon H. Charney Division of Cardiology. New York University Langone
Health. New York, NY, USA
Disclosures: Dr. Barbhaiya has received speaking fees/honoraria from
Abbott, Inc., and Medtronic, Inc. Dr. Aizer received fellowship support
from Abbott, Inc., Biotronik, Inc., Boston Scientific, Inc., and
Medtronic, Inc. Dr. Chinitz has received speaking fees / honoraria from
Abbott, Medtronic, Biotronik, Biosense Webster and Fellowship / Research
from Medtronic, Biotronik, and Biosense Webster. Remaining authors have
nothing to disclose.
Funding: None
Address for Correspondence:
Dr. Chirag Barbhaiya
Leon H. Charney Division of Cardiology
New York University School of Medicine
550 1st Avenue
New York, NY 10016, USA
Phone: 212-263-5555
Fax: 212-263-8685
E-mail address:
chirag.barbhaiya@nyumc.org
Our article reported risk factors for ICD lead failure at our medical
center, and we found an elevated risk of ICD lead failure in multiple
lead ICD systems implanted via cephalic venous access.(1) Our analysis
was prompted by recent literature related to durability of the Linox ICD
lead (Biotronik, Inc., Berlin, Germany), and we found similar, elevated
risk of ICD lead failure implanted in multiple lead systems via cephalic
access in Linox and non-Linox ICD leads. Given the small number of total
lead failures in the overall cohort (6 of 660), and the retrospective,
single-center nature of our analysis, we reviewed prior Linox ICD lead
durability manuscripts for evidence of increased risk of failure in
multiple lead ICD systems implanted via cephalic venous access. While no
prior manuscript evaluated this specific risk, we did find a trend
towards increased risk of lead failure in cohorts with greater
proportions of multiple lead systems, and greater proportions of systems
implanted via cephalic access, however these variables were included in
the analysis in a minority of prior studies.
Dr. Maas and colleagues express surprise at the high failure rate when
implanting multiple leads in our cohort. We would clarify that we
reported ICD lead failure in 4 of the 304 patients in our cohort with
multiple ICD leads, and that the frequency of lead failure in multiple
lead ICD systems was not statistically significantly different compared
to that of single lead ICD systems. In contrast, and surprisingly to us,
3 of 30 patients with multiple lead ICD systems implanted via cephalic
access experienced ICD lead failure, and the frequency of ICD lead
failure was significantly greater in this group compared to the
remaining cohort in Kaplan-Meier survival analyses.
Maas and colleagues question the reason for utilization of cephalic
access in 18% of patients, hypothesize that suboptimal implantation
technique may be responsible for the elevated lead failure rate, and
request clarification of lead failure mechanism. We did not
systematically collect rationale for venous access technique, and venous
access techniques was at the discretion of the implanting physician. Of
the 6 lead failures, 3 were related to lead noise, and 3 were related to
rising pacing thresholds. Of the three lead failures amongst patients
with multiple lead systems implanted via cephalic venous access, 2 were
related to lead noise, and 1 was related to a rising pacing threshold.
We believe that the lead noise may be related to insulation breach that
may be predisposed by lead-lead interactions in the region of the
cephalic vein. ICD leads were returned to the manufacturer on an ad hoc
basis, and no specific feedback was received from manufacturers related
to leads included in our analysis. All implanting physicians were
experienced operators, and there were no significant differences in
frequency of ICD lead failure by operator. We agree that implantation
technique may play an important role in lead failure risk, and our
analysis should prompt extra caution when implanting multiple leads via
cephalic venous access.
Citing the above limitations of our analysis, Dr Maas and colleagues
state that it is “too early to abandon cephalic vein access, even for
multiple lead systems.” They also review recent literature reporting
favorable acute outcomes of ultrasound guided axillary venous access. We
agree that our analysis paired with our literature review is best
considered hypothesis generating, and we hope that our analysis
encourages future studies to consider our findings when selecting
variables of interest in ICD lead durability studies. We share Dr. Maas
and colleagues’ favorable view of data supporting axillary venous
access, particularly in combination with ultrasound guidance. As a
result, given the available evidence of acceptable alternative
techniques, our practice is to favor axillary venous access during
implantation of multiple lead ICD systems, but we would not hesitate to
implant via cephalic venous access in the appropriate clinical scenario.
References
1. Barbhaiya CR, Niazi O, Bostrom J et al. Early ICD lead failure in
defibrillator systems with multiple leads via cephalic access. Journal
of cardiovascular electrophysiology 2020;31:1462-1469.