It is true that compared with the subclavian route there is likely to be a much lower incidence of pneumothorax, haemothorax and chylothorax with the ultrasound guided axillary approach. It is also true that in certain situations, the axillary approach may provide the only source of central venous access: for example, in severely burned patients.2
We feel, however, that the risks to local structures, notably the brachial plexus, and the increased risks of significant venous thrombosis and stenosis, make the axillary approach to central vein access comparatively less attractive than other forms of peripherally based central venous access, for example PICC or femoral vein lines.1 Routine use of axillary venous cannulation may also reduce the treatment options available to particular patient groups, notably for individuals requiring formation of arteriovenous fistulae for haemodialysis.
In the light of recent guidelines governing the use of ultrasound for central line insertion,3 and in the limited instances where axillary central line insertion may be indicated, Galloway and Bodenham's1 accurate description of the ultrasonic appearance will be of undoubted value. We would, though, urge careful patient selection.
1 East Grinstead 2 Oxford, UK
All routes of access have inherent advantages and disadvantages and it is up to the clinician to minimize the risk to an individual patient. A case series outlining this route of access has now been published in the BJA.4
Leeds, UK
References
1 Galloway S, Bodenham A. Ultrasound imaging of the axillary veinthe anatomical basis for central vein access. Br J Anaesth 2003; 90: 58995
2 Andel H, Rab M, Felfernig M, et al. The axillary vein central venous catheter in severely burned patients. Burns 1999; 25: 7536[CrossRef][Medline]
3 National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technological Appraisal Guidance 2002; 49, www.nice.co.uk
4 Sharma A, Bodenham AR, Mallick A. Ultrasound-guided infraclavicular axillary vein cannulation for central venous access. Br J Anaesth 2004; 93: 18892