Accessing The Axillary Vein
This is a guest post by Jack LeDonne (@jackledonnemd), Tom Petry and Peter Carr (@paedarg)
The Axillary Vein (AXV) has compelling advantages over other access sites for Central Venous Access Device (CVAD) insertion (namely the Internal Jugular Vein (IJV), Subclavian Vein (SCV) and the Femoral Vein). In particular, the AXV approach helps avoid iatrogenic complications during and after CVAD insertion.
The AXV traverses from the arm to the thorax in the infraclavicular fossa, where there is considerably less motion compared to the neck or the groin. Dressing maintenance is optimized at this site, reducing the risk of Catheter Related Blood Stream Infection (CRBSI), as it does for the SCV approach (Timsit et al, 2012).
The AXV is easily visualized with ultrasound, whereas the true SCV can be very difficult to visualize, particularly in the transverse view. The SCV lies in the bony tunnel bounded by the clavicle above and the first rib below. For this reason, the SCV is considered a non-compressible structure, whereas the AXV is easily compressible. This compressibility is apparent during pre-procedure ultrasound assessment of the central veins. Compressibility is important for the control of hemorrhagic events by direct pressure, particularly in coagulopathic patients. The AXV is also suitable as a site of insertion for tunnelled CVADs (O’Leary et al, 2012 and Sharma et al, 2004).
With experience, the approach to the AXV in the lateral aspect of the deltopectoral groove, either in plane (long axis) or out of plane (short axis) is straight forward for non-tunneled CVADs as our video demonstrates:
This site combines a low risk of pleural puncture, compressibility and the advantages of an infraclavicular site. For these reasons, the AXV is emerging as the preferred choice for non-tunnelled CVAD, in non-renal patients. The SCV is considered the preferred site for CVAD insertion based on decreased rates of CRBSI (Lorente et al, 2005), though a more recent meta-analysis called for a definitive large randomized controlled trial comparing each catheter site complication before the SCV can be unequivocally recommended (Parenti et al, 2010). Given its advantages, we suggest the AXV approach be included in any such study.
References
- Timsit JF, et al.Dressing disruption is a major risk factor for catheter-related infections*. Critical care medicine, 2012. 40(6): p. 1707. PMID: 22488003
- O’Leary R., et al. Ultrasound-guided infraclavicular axillary vein cannulation: a useful alternative to the internal jugular vein. British journal of anaesthesia, 2012. 109(5): p. 762-768. PMID: 22923635
- Sharma A, et al. Ultrasound-guided infraclavicular axillary vein cannulation for central venous access. British journal of anaesthesia, 2004. 93(2): p. 188-192. PMID: 15220180
- Lorente L, et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Critical Care, 2005. 9(6): p. R631. PMID: 16280064
- Parienti J-J, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults*. Critical care medicine, 2012. 40(5): p. 1627-1634. PMID: 22511140
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