Introduction

Common complications after radiofrequency ablation (RFA) of atrial fibrillation (AF) by pulmonary vein isolation (PVI) include vascular access site complications. To this day, there’s no published evidence of a beneficial effect caused by ultrasound (us)-guided venipuncture to establish femoral venous sheaths (2x12F + 1x6F + 1x7F) for the purpose of point-by-point catheter ablation in AF, performed under continuous oral anticoagulation.

Methods

2018 and 2019’s procedural data of our clinic’s Department of Electrophysiology were collected and analyzed retrospectively. We included all procedures before and after adjusting the workflow to an us-guided venipuncture as a standard feature to establish femoral venous access. AV-fistula, pseudoaneurysm and need of either interventional or surgical treatment of a vascular complication as well as blood transfusion were considered as access site complications. Moreover safety-endpoints and published data from the SAFER-register and the ESC-EHRA-atrial fibrillation registry were included in the statistical analysis.

Continuous data are given as mean ± standard error of the mean, categorical data are expressed as number and percentages. Differences between groups were determined by Student’s t-test, chisquare-test, and Fisher’s exact test using SPSS software. A p-value of <0.05 was deemed significant.

Results

Data of 263 patients before and 170 patients after adjustment of the workflow were included in the analysis. Baseline characteristics didn’t differ between the groups. Overall mean age was 68 ± 0,5 years, 49,9% of the patients were female and mean BMI was 28.9 ± 0,7 kg/m². In both groups the procedures‘ success rate amounted to 99% and the procedures took 208 ± 3 minutes on average.

If conventional venipuncture was performed, the total rate of vascular access site complications of our center showed reduced numbers compared to published data (3,42% vs. 7,9%). By using ultrasound-guidance these numbers decreased even further (3,42% vs. 0,6%; p<0,05). In particular, none of the patients needed interventional or surgical treatment if venous access was established using us-guidance (1,52% vs. 0%; p=0,17).

The rate of postprocedural stroke/TIA (0% vs. 0%), pericardial effusion (1,1% vs. 0,6%) and in-hospital mortality (0% vs. 0%) did not differ between the groups.

The percentage of patients being discharged on the first and second postprocedural day (77,6% vs. 71,8%, p=0,69) as well as mean duration of hospital stay (2,8d vs. 2,3d; p=0,64) did not differ. 

Discussion

In conclusion the retrospective analysis of our single-center data show that using ultrasound-guided venipuncture to establish femoral venous access is superior to conventional venipuncture regarding vascular access site complications in point-by-point radiofrequency ablation of atrial fibrillation by pulmonary vein isolation. At the same time, it preserves the procedure’s safety and efficacy. 

Outstandingly, the total rate of vascular access site complications had been significantly reduced resulting in a reduction of interventional or surgical treatment down to 0,0% in the us-guidance group. Ultrasound-imaging before performing venipuncture helps to identify complex or uncommon anatomical conditions and prevents access site complications. The authors recommend the use of ultrasound as standard in electrophysiological practice.