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 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[1] ; in particular, it poses little risk of pneumothorax.[2] This technique is widely used for the placement of pacing and defibrillation leads and chronic indwelling venous catheters.[3, 4, 5, 6]  In most patients, the cephalic vein is accessible for placement of long-term indwelling vascular devices.[7]

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 for cephalic vein cutdown include the following:

• Placement of pacing leads ^{[2, 8, 9]}
• 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) ^[10]
• Placement of temporary central venous catheters

Contraindications for cephalic vein cutdown include the following:

• 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 the risk of infection or the erosion of an implanted device left in place for an extended period)
• Ongoing ipsilateral phlebitis (this increases the risk of infection of an indwelling device)

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 ± 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.[11]

With the direct cutdown technique, cannulation can be achieved in 64-94.8% of cases for placement of pacing leads.[4, 5]

The success of the procedure increases when preoperative ultrasonographic mapping is done or contrast venography is performed to visualize the cephalic vein.[12, 13, 14]

Equipment used for cephalic vein cutdown includes the following:

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

Anesthesia

Local anesthesia with lidocaine is usually satisfactory when combined with procedural sedation. (See Local Anesthetic Agents, Infiltrative Administration and Procedural Sedation.) General anesthesia is very rarely necessary.

Positioning

Position the patient supine, in such a manner that his or her arm can be extended if necessary.

When vein spasm or a very small vein is encountered, advancement of the angiographic wire can be facilitated by "flooding" the vein with lidocaine; this almost uniformly results in significant increase of the vein diameter.

If dissection is problematic, the best maneuver is to make another venotomy more proximally and reattempt the cannulation.

Inability to advance the wire may be encountered. Fluoroscopy is critical to help with navigating the wire 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.

On very rare occasions, the cephalic vein traverses over the clavicle. When this occurs, the indwelling hardware (ie, pacing leads and cannulae) are exposed to significant mechanical flexion and external pressure (eg, from bra straps). In such a situation, the authors prefer not to use the cephalic vein for permanent placement of a pacing lead.[15]

In a small percentage (~5%) of patients, the cephalic vein is absent. If this appears to be the case, it is worthwhile to reexamine the layers of already-dissected tissue; it is not unusual to find the vein there.

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.[13, 16, 17, 18, 12, 19]

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.[20]

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. The use of one or two self-retaining retractors is helpful for achieving good visualization of the area.

The cephalic vein is nested in the groove between the deltoid and the pectoralis major. The depth at which the vein is visualized (see the images below) varies among patients.

Cephalic vein cutdown. Course of cephalic vein.

Cephalic vein cutdown. Alternative course and size of cephalic vein.

Once the vein is seen, carefully free it from the surrounding tissue, including the connective tissue inferior to the vein. A right-angle dissection forceps is 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. 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. Next, position and ligate the distal silk tie. This technique allows maximal lumen dilation and facilitates the venotomy. (See the image below.)

Cephalic vein cutdown. Cephalic vein is free from tissue. Proximal and distal ties are in place. Vein is now ready for 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. Confirm that the true lumen of the vein is opened; this will be evidenced 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 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 at direct placement of the pacing lead can be made. However, the authors prefer first to insert the 5-French dilator and advance the hydrophilic wire down to the innominate vein (see the image below).[21]  Usually, two wires can be placed with 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.

Cephalic vein cutdown. Second hydrophilic wire is advanced via 5F dilator.

Next, remove the sheath and advance it again over the single wire (see the image below). 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; as many as three pacing electrodes can be placed with this technique.

Cephalic vein cutdown. Hemostatic sheath in place.

After the pacing electrodes or indwelling catheters are passed, the proximal ligature can be tied to avoid backbleeding. Take care not to apply excessive force; the use of 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.

The percutaneous approach has been described for the cannulation of the cephalic vein.[22]  This approach is especially helpful in very obese patients in whom other central venous access may be very difficult.

First, use portable ultrasonography (US) 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 US guidance until backflow of blood is obtained. Then, advance the wire and advance an indwelling catheter over the wire.

A low rate of complication is seen with cephalic vein cannulation.[1] An 11% rate of complications has been published when this approach is used for placement of central indwelling catheters.[5]

Local hematoma, vein thrombosis, chronic venostasis, and infection have been reported to be related to cephalic vein cutdown.

The use of this procedure has not been as well studied in children as it has in adults. However, some reports indicate that it is safe and feasible in the pediatric population, with a low complication rate.[23, 24]