Background
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 places low mechanical stress on the indwelling hardware.
Cephalic vein cutdown results in low complication rates, particularly as compared with those of subclavian vein cannulation; 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, 4] In most patients, the cephalic vein is accessible for placement of long-term indwelling vascular devices. [5]
For information on other techniques for obtaining central venous access through upper-extremity veins, see Central Venous Access via Supraclavicular Approach to Subclavian Vein and Central Venous Access via Infraclavicular (Subclavian/Subclavicular) Approach to Subclavian Vein.
Indications
Indications for cephalic vein cutdown include the following:
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Central venous access for long-term infusion therapy - A meta-analysis by Klaiber et al found open cephalic vein cutdown to be generally superior to closed cannulation of the subclavian vein for implantation of totally implantable venous access ports (TIVAPs) [8]
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Placement of temporary central venous catheters
Contraindications
Contraindications for cephalic vein cutdown include the following:
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Known occlusion of the cephalic vein
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Chronic ipsilateral venostasis
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Ipsilateral radical resection of the lymph nodes
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Ipsilateral mastectomy
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Chronic ipsilateral lymphedema
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Extensive scarring of the incision site (this may increase the risk of infection or the erosion of an implanted device left in place for an extended period)
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Ongoing ipsilateral phlebitis (this increases the risk of infection of an indwelling device)
Technical Considerations
Anatomy
Approximately 95% of individuals have a cephalic vein. About 80% of the time, this vein is located superficially in the deltopectoral groove. Rarely, deep exploration is needed to identify the vein.
The vein diameter ranges from 0.1 to 1.2 cm, with an average size of 0.8 cm ± 0.1 cm. The average length is about 4.8 cm. In 0.2% of cases, the vein has a supraclavicular course and should not be used for pacing lead insertion, because it exposes the hardware to mechanical stress and risk of fracture. Often, the vein receives two or three tributaries, but these rarely cause difficulty with accessing the vein. [9]
Outcomes
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 ultrasonographic mapping is done or contrast venography performed to visualize the cephalic vein. [10, 11, 12]
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Cephalic vein cutdown. Course of cephalic vein.
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Cephalic vein cutdown. Hemostatic sheath in place.
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Cephalic vein cutdown. Second hydrophilic wire is advanced via 5F dilator.
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Cephalic vein cutdown. Alternative course and size of cephalic vein.
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Cephalic vein cutdown. Lead placed previously via cephalic vein.
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Cephalic vein cutdown. Cephalic vein is free from tissue. Proximal and distal ties are in place. Vein is now ready for venotomy.
