Axillary Vein Catheterization Technique

Updated: Apr 08, 2016
  • Author: Ethan Levine, DO; Chief Editor: Vincent Lopez Rowe, MD  more...
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Technique

Fluoroscopy-Guided Access

With the patient appropriately positioned (see Periprocedural Care, Patient Preparation), an assessment of the surface anatomy is helpful, not only for locating the vein but also for planning the location of the incision if the goal is to implant a pacemaker or implantable cardioverter-defibrillator (ICD).

Locate the inferior clavicular margin, the coracoid process, and the deltopectoral groove. In addition, palpate for the pulse of the axillary artery; in thin patients, this can be readily appreciated in the infraclavicular fossa.

Whereas the surface anatomy is undoubtedly important, these landmarks can be misleading, especially in larger patients. In some patients, especially elderly patients and those with chronic obstructive pulmonary disease (COPD), the clavicle is often displaced superiorly and cannot necessarily be used as a landmark. It is essential to remember that the constant relationship of the axillary vein is to the first rib, not to the clavicle or the surface anatomy. [8]  Keeping this point in mind can help avoid inadvertent arterial puncture as a result of using the clavicle as a landmark.

The authors' preference is first to identify the surface anatomy and then to lay the needle and syringe on the skin surface over the intended course of the puncture and perform a fluoroscopic study (see the image below). This technique can avoid creating a subcutaneous pocket that is too distant from the intended access site.

Fluoroscopic image shows 25-gauge local anesthetic 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).

Once the surface and fluoroscopic anatomy have been identified, make the incision and carry it to the level of the prepectoral fascia. At this level, create a pocket large enough to accommodate the device to be implanted. Ensure hemostasis before directing attention to accessing the vein.

To access the vein, advance the needle under fluoroscopic guidance toward the greatest curvature of the first rib while maintaining negative traction on the plunger of the syringe. By maintaining a relatively steep angle (45-70°), the possibility of passing beyond the rib and entering the pleural space is minimized. As a precaution against pneumothorax, do not advance the needle beyond the medial border of the first rib. If the vein is not entered upon the initial attempt, withdraw the needle, redirect it, and advance it again in a similar manner.

Remember that once the needle passes below the clavicle, if the subclavian artery is entered, it is noncompressible. Because the axillary and subclavian arteries lie in a superior or cephalad relation to the respective veins, redirecting the needle in a more cephalad direction should be done in a gradual stepwise fashion.

Once the vein is entered, remove the syringe from the needle, and pass a guide wire into the vessel. At this point, quickly pan the fluoroscopic image to the level of the diaphragm to confirm that the guide wire passes to the inferior vena cava (IVC) below the diaphragm (within the shadow of the liver); this confirms that the access is venous rather than arterial and helps ensure that a sheath is not inadvertently placed into the axillary artery. (See the video below.) Observing the course of the guide wire can also alert the operator to the presence of venous anomalies such as a persistent left superior vena cava (SVC).

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.

Patients who require central venous cannulation are often quite ill and may have significant disorders of oxygenation as well as cardiac valvular pathology. Consequently, the color of the flash of blood cannot always be relied upon to distinguish venous from arterial blood. In addition, patients with marked tricuspid regurgitation may exhibit pulsatile flow in the axillary vein.

Once venous access is confirmed, remove the needle and place a sheath and dilator over the guide wire.

If gaining entry into the vein is difficult, several steps can be taken to facilitate the process. If the difficulty is likely due to an awkward access angle because the pocket is too lateral with respect to the access point, the needle may be redirected to access the vein as it overlies the second rib rather than the first. This is the preferred initial approach of many operators. To access the vein as it courses over the second rib, advance the needle exactly as as described above, but direct it to the area where the second and third ribs overlie each other on the fluoroscopic image.

If the difficulty is not due to the access angle, intravenous (IV) contrast may be employed to aid in gaining access. To do this, inject a small amount of radiocontrast (typically 10 mL) into the ipsilateral arm. Follow immediately with a vigorous flush. Access may be gained in real time while the contrast is still visible via fluoroscopy within the lumen; alternatively, a fluoroscopic image of the contrast-filled vein may be stored as a roadmap.

Occasionally, injection in this fashion selectively enhances the cephalic vein rather than the axillary vein. This can usually be avoided by placing the IV line in the ulnar aspect of the forearm rather than the radial aspect. When the cephalic vein is selectively enhanced, the application of a tourniquet or blood pressure cuff at low pressure preferentially redirects flow toward the axillary vein. [9]

If the patient has undergone an invasive electrophysiology study before the venous access procedure, a so-called “poor man’s venogram” can be performed. Advance one of the electrophysiology catheters from the femoral vein to the axillary vein under fluoroscopic guidance. A fluoroscopic snapshot of the catheter positioned in the axillary system (see the image below) may then be saved as a roadmap for future access. [10]

Fluoroscopic image demonstrates ablation catheter 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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Ultrasound-Guided Access

Techniques for accessing the axillary and subclavian system with the aid of ultrasonography are well-recognized aids for gaining access to the axillary system for the purposes of central venous line insertion and brachial plexus blockade, as well as dialysis catheter implantation. [5, 11, 12, 13, 14]

To access the vein under ultrasound guidance, place the patient in the supine position, preferably with 10º-15º of Trendelenburg, and prepare the patient in the usual sterile manner. Cover the ultrasound probe with a sterile wand cover, and obtain an image in which both the axillary vein and the artery are seen.

Next, position the needle and syringe to be used for access at the point where the center of the probe meets the skin surface. This positioning ensures that the needle remains in the ultrasound field of view as it is advanced. Advance the needle while maintaining negative pressure on the plunger and observing the ultrasound image.

Once the axillary vein is seen to compress, puncture the anterior wall of the vein with a brief staccato motion of the needle. Once the needle is seen to enter the vein and blood flashes into the syringe, remove the syringe and place a guide wire into the lumen. From this point, a sheath and dilator may be placed in the usual fashion.

If both walls of the vein are punctured, maintain negative pressure on the syringe and withdraw until the flash of blood is seen, then thread the guide wire as described above. Double-wall puncture of the vein is fairly common and typically does not result in any significant adverse outcome.

If the axillary artery is inadvertently entered, remove the needle and apply firm pressure over the vessel for 3-5 minutes. This is typically sufficient to prevent ongoing bleeding and hematoma formation. Hemostasis can be confirmed with the ultrasound image, as well.

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Blind Access

Whereas blind access techniques have been described, [15, 6] they are not routinely applied in clinical practice. The blind techniques, which are based on surface anatomy and palpable landmarks, are hampered by the fact that the position of the axillary vein depends on the position of the ipsilateral arm and the close relation of the axillary vein to the axillary artery. The greatest concern with the use of a truly blind technique is the risk of pneumothorax as a consequence of the inability to visualize the needle tip as it advances.

In order to perform a blind stick, identify the coracoid process and deltopectoral groove, paying attention to the angle of the groove. Make an incision at the level of the coracoid process, and carry it to the level of the prepectoral fascia. At this point, the pectoralis muscle and the deltopectoral groove can be directly visualized.

Advance a needle through the pectoralis muscle at a point 1-2 cm medial to the deltopectoral groove, pointed in a superior and medial direction, while maintaining an orientation parallel to that of the deltopectoral groove. By maintaining a shallow angle of roughly 45º to the chest wall, the risk of pneumothorax is diminished.

In Belott’s description of the above technique, fluoroscopy was used and the technique carried out as described previously when blind access was not successful after a few passes. [15] Because the incision is long enough to visualize the deltopectoral groove, a cephalic cutdown remains a viable bailout option if the blind access method fails. If the blind access technique is unsuccessful, the other techniques described above can also be used.

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Complications

Accessing the axillary venous system is quite safe in experienced hands. Potential complications include the following:

When recognized promptly, these complications rarely result in significant morbidity.

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