Cephalic Vein Cutdown 

Central venous access via the upper extremity veins is used for various purposes because it is easy to perform and is convenient for the patients. The relatively low mobility of the central veins of the upper extremity and the neck also affords low mechanical stress on the indwelling hardware. The cephalic vein cutdown results in low complication rates; rates are particularly low when compared with subclavian vein cannulation, since cephalic vein cutdown poses no risk of pneumothorax. This technique is widely used for the placement of pacing and defibrillation leads and chronic indwelling venous catheters.^{[1, 2, 3]} The cephalic vein is accessible in most patients for placement of chronic indwelling vascular devices.^{[4, 5]}

For information on other techniques to obtain central venous access through upper extremity veins, see eMedicine articles Central Venous Access, Subclavian Vein, Supraclavicular Approach and Central Venous Access, Subclavian Vein, Subclavian Approach.

• Placement of pacing leads
• Central venous access for chronic infusion therapy
• Placement of temporary central venous catheters

• Known occlusion of the cephalic vein
• Chronic ipsilateral venostasis
• Ipsilateral radical resection of the lymph nodes
• Ipsilateral mastectomy
• Chronic ipsilateral lymphedema
• Extensive scarring of the incision site (this may increase risk of infection or the erosion of a chronically implanted device)
• Ongoing ipsilateral phlebitis (this increases the risk of infection of indwelling device)

• Local anesthesia with lidocaine is usually satisfactory when combined with procedural sedation. For more information, see Local Anesthetic Agents, Infiltrative Administration and Procedural Sedation.
• General anesthesia is very rarely necessary.

• Surgical blade, No. 11
• Right-angle forceps
• Metzenbaum curved dissecting scissors
• Vein pick
• Right-angle dissecting forceps
• Blunt self-retaining retractors (eg, Weitlaner), 2
• Vascular forceps
• Dilator, 5F, or large-gauge peripheral intravenous cannula
• Hydrophilic angiographic wire (eg, Glidewire, Zipwire) with angled tip torquer tool
• Fluoroscope

• Position the patient supine.
• The patient should be positioned so that his or her arm can be extended if necessary.

Direct cutdown

For the direct cutdown approach, a 5-cm incision overlying the deltopectoral groove is usually satisfactory. If multiple locations for vascular access are needed, the superior aspect of the incision should be aimed at the lateral one third of the clavicle to facilitate axillary vein cannulation. This approach may be more commonly used in patients who require insertion of multiple pacing leads. Multiple leads can often be placed via the cephalic vein.^[6]

• To avoid accidental trauma to the cephalic vein, the authors prefer to proceed with blunt dissection of the tissue and, in particular, the deeper layers.
• Use 1-2 self-retaining retractors to visualize the area well.
• The cephalic vein is nested in the groove between the deltoid and pectoralis major muscles. The depth at which the vein is visualized, as shown below, varies among patients. Cephalic vein course. An alternative course and size of the cephalic vein.
• Once the vein is seen, carefully free it from the surrounding tissue, including the connective tissue inferior to the vein.

  • Right-angle dissection forceps are very helpful in this situation.
  • Advance the forceps inferior to the vein. Separate the connective tissue from the cephalic vein by repeatedly opening and closing the forceps as shown below. The cephalic vein is free from the tissue. Proximal and distal ties are in place. The vein is now ready for the venotomy.
• Place the proximal (double-looped) tie over the vein. Apply traction until the vein engorges.
• Then secure the tie to the sterile cover to avoid backflow of blood from the vein.
• At this time, position and ligate the distal silk tie. This technique allows for maximal lumen dilation and facilitates the venotomy.
• Using vascular forceps, gently pick up the superior wall of the vein. Perform the venotomy with the No. 11 surgical blade.

  • The venotomy should be done in the most distal aspect of the exposed vein segment. Advance the blade with the cutting edge in the upper one third of the vein’s thickness.
  • Assure that the true lumen of the vein is opened. This is evident by the flow of blood through the venotomy.
• Several techniques can be used to cannulate the vein. From this point on, fluoroscopy should be used to visualize the leads or wire that is being advanced (this is particularly helpful when unusual anatomy is encountered). Certainly, finesse rather than force should be used with these maneuvers to avoid tearing the vein.
• Gently stretch the venotomy site with a vein pick. Ease the proximal ligature open to facilitate passing of the hardware.
• When the vein is particularly generous in size, an attempt for direct placement of the pacing lead can be made. The authors prefer though to first insert the 5F dilator and advance the hydrophilic wire down to the innominate vein, as depicted in the image below.^[7] A second hydrophilic wire is advanced via 5F dilator.
• Usually, 2 wires can be placed using this technique. When the vein is very small, the operator can initially advance the sheath over the wire, remove the dilator while retaining a wire, and advance another wire through the sheath.
• Next, remove the sheath and advance it again over the single wire as shown below.Hemostatic sheath in place.
• This technique is very useful for placement of multiple pacing electrodes even if the vein is small. The sheath placement facilitates stretching of the vein that can be quite remarkable; up to 3 pacing electrodes can be placed using this technique.
• After the pacing electrodes or indwelling catheters are passed, the proximal ligature can be tied to avoid back bleeding. Take care not to apply extensive force, as too much force may tear the vein and make hemostasis very difficult. In this situation, additional proximal sutures can be placed to control the bleeding; however, this maneuver poses some risk of inadvertently puncturing the pacing lead or indwelling catheter.

Percutaneous approach

• The percutaneous approach has been described for the cannulation of the cephalic vein.^{[8, 9]} This approach to cephalic vein cannulation is especially helpful in very obese patients in whom other central venous access may be very difficult.
• First, use portable ultrasonography to identify the location of the vein.
• Once the site is confirmed, prepare it in a sterile fashion.
• Position the sterilely covered ultrasound probe over the deltopectoral groove.
• Place the needle in the device holder and advance it under ultrasonographic guidance until backflow of blood is obtained.
• Then, advance the wire and advance an indwelling catheter over the wire.

Success

• With the direct cutdown technique, cannulation can be achieved in 64-94.8% of cases for placement of pacing leads.^{[2, 3]}
• The success of the procedure increases when preoperative ultrasound mapping is done or contrast venography performed to visualize the cephalic vein.^{[10, 11]}

• Vein spasm: When vein spasm or a very small vein is encountered, advancement of the angiographic wire can be facilitated after "flooding" the vein with lidocaine. This almost uniformly results in significant increase of the vein diameter.
• Dissection: In this situation, the best maneuver is to make another venotomy more proximally and reattempt the cannulation.
• Inability to advance the wire: Fluoroscopy is critical to help with the wire navigation though the venous anatomy. Hydrophilic wires also help advance the wire through tortuous anatomy. In very difficult cases, a torquer tool should be used to help with wire navigation. Sometimes, arm extension also facilitates passing of the wire.
• Over the clavicle course: On very rare occasions, the cephalic vein traverses over the clavicle. In that case, the indwelling hardware (ie, pacing leads, cannulae) are exposed to significant mechanical flexion and external pressure (eg, bra straps). In such a situation, the authors prefer not to use the cephalic vein for permanent placement of a pacing lead.^[12]
• Failure of cannulation: Failure of cannulation because of vein occlusion is not often seen. The presence of indwelling leads (in particular, defibrillation leads), a history of vein thrombosis or hormonal therapy, and female sex have been identified as risk factors for vein occlusion.^{[11, 13, 14, 15, 10, 16]}

• A low rate of complication is seen with cephalic vein cannulation. An 11% rate of complications has been published when this approach is used for placement of central indwelling catheters.^[3]
• Local hematoma, vein thrombosis, chronic venostasis, and infection have been reported to be related to cephalic vein cutdown.