Equipment
Equipment used for axillary vein catheterization includes the following:
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Surgical blade (No. 10 or 15)
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Weitlaner retractors
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Forceps
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Bovie electrocautery pen
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Army-Navy retractors
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Needle (18 gauge) and slip-tip syringe
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Soft J-tip guide wire
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Hemostatic sheath and dilator system
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Fluoroscope
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Ultrasound machine
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Intravenous (IV) radiocontrast agent
Patient Preparation
Anesthesia
Local anesthesia with 1% lidocaine is sufficient for accessing the axillary system with the aim of placing a central venous line. For more information, see Local Anesthetic Agents, Infiltrative Administration.
When the patient is particularly anxious, or when the vein is accessed for the purpose of placing a pacemaker or defibrillator, some degree of procedural sedation is customary and adds to patient comfort. Typically, sedation is achieved with titrated doses of IV benzodiazepines and narcotics; when the services of an anesthesiologist are available, propofol may be used. For more information, see Procedural Sedation.
General anesthesia is rarely required.
Positioning
Place the patient in the supine position. Prepare and drape the area in the customary sterile manner. Trendelenburg positioning is helpful because it leads to engorgement of the upper-extremity venous system. When Trendelenburg positioning is used, an appropriate compensation with cranial angulation of the fluoroscopic camera should be employed to maintain the standard view.
When a patient has difficulty lying flat and a wedge-shaped pillow or reverse Trendelenburg positioning is used, the image intensifier should be rotated to a degree of caudal angulation matching the degree to which the patient is elevated.
In addition, some practitioners use a folded towel or roll between the scapulae, which moves the lateral aspect of the clavicles posteriorly. This potentially facilitates access, especially in patients of greater habitus in whom the vein may be relatively deep.
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Venogram with radiocontrast delineates axillary and cephalic venous system. Brachial vein (D) receives cephalic vein (C) as it courses medially to become axillary vein (A=lower border of axillary vein; B=upper border of axillary vein).
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Fluoroscopic image shows 25-gauge local anesthetic needle laid across intended access site prior to infiltration with lidocaine. Note preferred access points at lateral margin of the first rib (A) and at point where second and third ribs overlie each other (B).
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Fluoroscopic image demonstrates ablation catheter advanced from right femoral vein to te left axillary vein. Note how catheter delineates location of the vein, serving as guide for accessing vessel.
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Fluoroscopic loop demonstrates axillary access. Needle enters axillary vein at lateral margin of first rib. Guide wire is then passed into vessel and observed to pass smoothly through axillary and subclavian veins to superior vena cava (SVC), right atrium, and, finally, to level in inferior vena cava (IVC) below diaphragm. Note presence of existing guide wire placed moments earlier in this patient, who was receiving dual-chamber pacemaker.
