Ultrasound-guided infraclavicular axillary vein cannulation for central venous access {

British Journal of Anaesthesia 93 (2): 188 92 DOI: 10.1093/bja/aeh187 Advance Access publication June 25, 2004 Ultrasound-guided infraclavicular axillary vein cannulation for central venous access { A. Sharma, A. R. Bodenham* and A. Mallick Department of Anaesthesia, General Infirmary at Leeds, Leeds Teaching Hospitals, Great George Street, Leeds LS1 3EX, UK *Corresponding author. E-mail: andy.bodenham@leedsth.nhs.uk Background. Infraclavicular axillary vein cannulation is not commonly used for central venous access because identifying the surface landmarks is difficult. Ultrasound guided axillary vein puncture has not been well described. We assessed ultrasound imaging to guide catheterization of the infraclavicular axillary vein. Methods. In 200 consecutive patients we attempted to catheterize the axillary vein using ultrasound imaging. After successful venepuncture, a tunnelled Hickman line was inserted for long-term central venous access. Surface landmarks of the skin puncture site were measured below the clavicle. We measured the depth of the vein from the skin, the length of the guidewire from skin to carina and the final length of catheter that was inserted. Results. The axillary vein was successfully punctured with the help of ultrasound imaging with first needle pass in 76% of patients. The axillary vein was catheterized successfully in 96% of the cases. Guidewire malposition was detected and corrected by fluoroscopy in 15% of cases. Complications included axillary artery puncture in three (1.5%) and transient neuralgia in two (1%) cases. Conclusion. Ultrasound-guided catheterization of the infraclavicular axillary vein is a useful alternative technique for central venous cannulation with few complications. Br J Anaesth 2004; 93: 188 92 Keywords: catheters, central venous; techniques, ultrasound; veins, axillary Accepted for publication: February 14, 2004 Infraclavicular axillary vein puncture guided by anatomical landmarks has been described as a route of access to the central veins. 12 It shares many features of the subclavian approach but because the landmarks are not easily identified 3 the technique is not in routine use. Other approaches to the axillary vein via the upper arm or axilla have also been described but again are not widely used. 4 We use ultrasound guidance increasingly for central venous access, as suggested by recent UK National Institute of Clinical Excellence (NICE) guidelines. 56 However, the subclavian vein is not easily imaged with ultrasound because of the clavicle. This limitation can be avoided if a more lateral approach is used, using the infraclavicular axillary vein. Using ultrasound, we found that more laterally the axillary vein lies further away from the chest wall and the artery. 7 These observations suggested that complications could be reduced using a more lateral axillary approach. This approach has also been described for brachial plexus nerve block guided by ultrasound. 8 We assessed the use of ultrasound to guide axillary vein catheterization. Methods After approval by the hospital ethics committee, we enrolled 200 consecutive patients who were to have tunnelled Hickman line insertion via the subclavian route. All clinical procedures were in routine use but the study involved extra measurements and data collection. Patients gave written informed consent. Procedures were performed in theatres on a planned vascular access list, or ad hoc on an acute list, with immediate access to ultrasound and fluoroscopy. Of the three operators, only one (ARB) was already familiar with the ultrasound-guided technique of axillary vein puncture. Routine monitoring included pulse oximetry, electrocardiography and non-invasive blood pressure measurement. Intravenous access was established and patients were given intermittent doses of fentanyl and midazolam, to obtain conscious sedation. Oxygen was given via nasal cannulae. { This article is accompanied by Editorial II. # The Board of Management and Trustees of the British Journal of Anaesthesia 2004

Ultrasound for axillary vein cannulation Both infraclavicular areas were examined by ultrasound to assess the suitability of the veins. We used the right axillary vein as a first choice and then the left. We chose a site where the vein was of adequate size, and not directly over the artery or the chest wall. Cannulation technique Patients were placed 15 head down with their arms supported at their sides. The operating field, including the neck area, was prepared with alcoholic chlorhexidine 0.5%. The vein was imaged using either a Site Rite device with 7.5 MHz probe (Dymax=Bard, Pittsburgh, PA, USA) or a SonoSite ilook device with a 5=10 MHz probe (SonoSite, Biggleswade, UK). The skin and subcutaneous tissues were infiltrated with lignocaine 0.5% 30 40 ml with 1:200 000 epinephrine. The vein and artery were imaged in cross-section together with the chest wall. An 18-gauge introducer needle was advanced at a steep angle towards the vein, guided by the orientation of the ultrasound probe (Fig. 1). The needle tip was seen as a moving bright spot associated with distortion of the tissues (Fig. 2). Gentle movements helped to identify the needle tip position. The tip was then seen indenting the vein wall. It was then either advanced into the vein or withdrawn if the vein was penetrated through both walls until blood could be aspirated freely into a syringe. The depth of the vein from the skin was calculated from measurements of the needle in situ with a sterile ruler. This was an approximation, as the needle was not perpendicular to the vein and was often moved slightly to facilitate threading the guidewire. We recorded the numbers of times the vein penetrated through both walls and contact with the rib cage occurred. The guidewire was shown by fluoroscopy and repositioned if necessary, so that its J tip was at the level of the carina. The distance from the puncture site to the carina was measured by markers on the guidewire and a sterile ruler. A single- (9.6 Fr) or double-lumen (11 Fr) catheter (Lifecath Hickman, Vygon UK, Cirencester, UK) was chosen according to clinical needs. The catheter and cuff were tunnelled subcutaneously from an exit site on the anterior chest wall to the skin puncture site. The catheter was cut to a length 4 cm longer than the distance from the skin to the carina. A dilator and splitting sheath were passed over the guidewire into the vein. The catheter was then inserted through the splitting sheath and its position checked and corrected, if necessary, by fluoroscopy. We adjusted the catheter tip to lie at the junction of the right atrium and the superior vena cava. The length of the catheter could be changed by moving the anchoring cuff along its subcutaneous track. Any changes were recorded and the internal length of the catheter was calculated. The surface relations of the skin puncture site were measured from the clavicle (Fig. 3). These included the distance from the puncture site to the lower border of the clavicle and to an imaginary traditional landmark site for subclavian access. The latter was taken to be 1 cm below the junction of medial 1=3 and lateral 2=3 of the clavicle. A chest X-ray was performed 2 h later. We recorded any complications, such as arterial puncture, transient neuralgic Fig 1 Approach to the right axillary vein. The ultrasound probe (U) in a sterile sheath has been used to show the axillary vessels in cross-section. Note the steep angle of approach and insertion depth of the introducing needle (length 7 cm) via the skin puncture site (A). Blood has been aspirated into the syringe after the needle enters the vein. Fig 2 This cross-sectional ultrasound image of the right infraclavicular area shows the right axillary vein (V) in the centre of the screen and the artery (A) deeper and superiorly. The path of the advancing needle is seen above the vein. The white arrow shows the approximate needle-tip position. The needle position is easier to see when it is being moved during real-time imaging. 189

Sharma et al. Table 1 Results of cannulation Ultrasound screening of axillary vein in 200 patients Considered suitable (n=196) Successful axillary puncture and catheter placement in 194 patients Failed in 2 cases Unable to thread guidewire and venous spasm after axillary artery puncture Considered unsuitable (n=4) Obese patient with narrow axillary veins Bilateral thrombosed axillary veins from previous catheters Fig 3 A patient with a single-lumen Hickman catheter inserted via the right infraclavicular axillary vein. Surface markings (sternal notch and right clavicle) have been drawn with a sterile marker. Point H represents an approximate traditional skin landmark site for subclavian vein puncture. The site of axillary vein puncture is seen further laterally with one suture. The exit site of the tunnelled catheter is more inferior on the anterior chest wall. pain and pneumothorax. The patients were followed up by a ward visit after the procedure and by telephone 6 weeks later, to determine progress and complications. Results We studied 200 consecutive patients (113 males and 87 females) over 11 months. The mean age of the patients was 58.7 (range 18 87) yr. Their height and weight (mean, SD) were 168.5 (9.4) cm and 70.0 (15.2) kg respectively. Indications for the procedure were chemotherapy for malignancy in 193 patients and long-term antibiotic therapy or total parenteral nutrition in seven patients. The axillary vein was seen with ultrasound in all patients but was considered unsuitable in four (Table 1). Axillary vein puncture and catheterization was successful in 194 of 196 patients, 153 on the right and 41 on the left. Cannulation was successful on the first, second and third needle pass in 76, 16 and 6% of the cases respectively. The internal jugular route was used, with ultrasound guidance, in the remaining six cases. The surface relations (Fig. 3) of puncture site are shown in Table 2. The relative lateral position of a final needle position, compared with traditional subclavian placement, is illustrated in Fig. 4. The length (mean, SD) of the catheter sited via the right side was 21.3 (2.2) cm and that from the left was 24.5 (2.5) cm. The axillary vein was transfixed and blood was aspirated on withdrawal of the needle in 54 (28%) cases. Contact with the rib cage was felt by the needle in 5.4% of procedures. The complications are listed in Table 3. The artery was punctured in three patients (1.5%). This was treated Unable to puncture axillary vein in 3 attempts Table 2 Measurements from the venepuncture site (Fig. 3) Measurements (cm) Mean (SD) Narrow axillary vein with multiple small channels Moderately obese patient with deeply located narrow axillary vein Skin puncture site to vein 4.6 (1.0) Skin puncture site to lower border of clavicle 4.45 (0.93) Skin puncture site to traditional subclavian site 5.02 (1.2) On right side On left side Guidewire length from puncture site to carina 17.3 (2.1) 20.5 (2.8) Catheter length from puncture site to the right atrium=superior vena cava junction 21.3 (2.2) 24.5 (2.5) Fig 4 A fluoroscopy image after insertion of an introducing needle (N) into the right axillary vein. The tip of the needle is just lateral to the jet of X-ray contrast shown by the tip of the white arrow. A small volume of injected X-ray contrast delineates the axillary vein draining into the subclavian vein (V) and superior vena cava. Paravalvular venous sinuses are seen just medial to the needle tip. C=clavicle; R=first rib. by 5 min of manual compression. There were no obvious external haematomas or other sequelae. Transient neuralgia was felt by two patients during guidewire or dilator insertion. The guidewire and catheter malpositions, which were 190

Ultrasound for axillary vein cannulation Table 3 Complications in 194 patients Arterial puncture 3 (1.5%) Pneumothorax 0 Extravascular placement 0 Transient neuralgia 2 (1%) Table 4 Guidewire and catheter malposition Via right axillary vein (n=153) Via left axillary vein (n=41) Guidewire malposition (n=30) Internal jugular vein (ipsilateral or 18 (11.8%) 6 (14.6%) contralateral) Subclavian=innominate vein 1 (0.6%) 0 (contralateral) Azygos vein 0 0 Coiled in the superior vena cava 4 (2.6%) 1 (2.4%) Catheter malposition (n=25) Internal jugular vein 10 (6.5%) 2 (4.8%) (ipsilateral or contralateral) Subclavian=innominate vein 5 (3.3%) 0 (contralateral) Azygos vein 1 (0.6%) 0 Coiled in the superior vena cava 4 (2.6%) 3 (7.3%) recognized and subsequently corrected by fluoroscopy, are listed in Table 4. After 6 weeks, 87% of catheters were still in place and working. Eight had been removed after treatment had finished. Four patients developed infections related to the catheter, requiring catheter removal, despite antibiotic therapy. Two had accidental dislodgement and one patient developed clinically significant axillary vein thrombosis, which required treatment with anticoagulants. Discussion Ultrasound guidance can reduce complication rates and increase the success of cannulation. 9 11 NICE recently recommended routine use of ultrasound to guide cannulation of the internal jugular vein 56 but concluded there was insufficient evidence for its use at other sites. We did not perform a randomized control study comparing landmark-guided subclavian vein puncture with ultrasoundguided axillary vein puncture because: (i) two of the operators had limited experience with the use of ultrasound; (ii) the patency of the axillary veins had to be assessed before venepuncture in patients who had already had long-term subclavian catheters; (iii) we already used ultrasound to locate veins either routinely or if blind puncture of subclavian vein proved difficult, and we were reluctant to use blind cannulation; and (iv) complication rates are low, such as pneumothorax (1 2%) and arterial puncture (3.4%), 12 when landmark methods are used by experienced operators. A very large trial would be needed to have adequate power to prove a benefit from the use of ultrasound. The frequency of complications in this study was low and compared favourably with previous landmarkguided studies, despite inexperience of two of the operators in this technique. 12 The frequencies of guidewire and catheter misplacement (15.5 and 12.9% respectively) are similar to those in other reports of subclavian access (15%). 12 This is a limitation of both techniques unless fluoroscopy is used. The ultrasound-guided axillary approach offers a number of potential advantages over landmark subclavian techniques. The anatomy favours ultrasound guidance and less complications. Manual compression of the axillary artery or surgical access is possible if arterial damage is caused. The puncture site is further away from potential sources of infection in patients with tracheostomy, central chest wall burns or sternotomy wounds. Some patients will be unsuitable for this approach because of variation in anatomy. 7 We found that axillary vein puncture is more difficult in obese patients, where the vein is deeper and may be beyond the range of higher-frequency ultrasound probes. Deeper veins may cause a difficult angle for the guidewire, dilators and catheters to traverse. A repeat puncture with the needle at a less acute angle to the vein may be required to facilitate passage of guidewires and catheters centrally. In this series the mean length of catheter inserted from the skin puncture site (21.4 cm on the right and 24.6 cm on the left) gives guidance for this route of access and is longer than typically used for the subclavian or internal jugular routes. In conclusion, axillary vein puncture guided by ultrasound is a useful alternative to the landmark-guided subclavian approach for central venous access, and may cause less complications. References 1 Nickels RWD. 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