Department of Anaesthesia, General Infirmary at Leeds, Leeds Teaching Hospitals, Great George Street, Leeds LS1 3EX, UK
* Corresponding author. E-mail: andy.bodenham{at}leedsth.nhs.uk
Accepted for publication February 14, 2004.
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Abstract |
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Methods. In 200 consecutive patients we attempted to catheterize the axillary vein using ultrasound imaging. After successful venepuncture, a tunnelled Hickman line was inserted for long-term central venous access. Surface landmarks of the skin puncture site were measured below the clavicle. We measured the depth of the vein from the skin, the length of the guidewire from skin to carina and the final length of catheter that was inserted.
Results. The axillary vein was successfully punctured with the help of ultrasound imaging with first needle pass in 76% of patients. The axillary vein was catheterized successfully in 96% of the cases. Guidewire malposition was detected and corrected by fluoroscopy in 15% of cases. Complications included axillary artery puncture in three (1.5%) and transient neuralgia in two (1%) cases.
Conclusion. Ultrasound-guided catheterization of the infraclavicular axillary vein is a useful alternative technique for central venous cannulation with few complications.
Keywords: catheters, central venous ; techniques, ultrasound ; veins, axillary
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Introduction |
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We use ultrasound guidance increasingly for central venous access, as suggested by recent UK National Institute of Clinical Excellence (NICE) guidelines.5 6 However, the subclavian vein is not easily imaged with ultrasound because of the clavicle. This limitation can be avoided if a more lateral approach is used, using the infraclavicular axillary vein. Using ultrasound, we found that more laterally the axillary vein lies further away from the chest wall and the artery.7 These observations suggested that complications could be reduced using a more lateral axillary approach. This approach has also been described for brachial plexus nerve block guided by ultrasound.8
We assessed the use of ultrasound to guide axillary vein catheterization.
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Methods |
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Routine monitoring included pulse oximetry, electrocardiography and non-invasive blood pressure measurement. Intravenous access was established and patients were given intermittent doses of fentanyl and midazolam, to obtain conscious sedation. Oxygen was given via nasal cannulae.
Both infraclavicular areas were examined by ultrasound to assess the suitability of the veins. We used the right axillary vein as a first choice and then the left. We chose a site where the vein was of adequate size, and not directly over the artery or the chest wall.
Cannulation technique
Patients were placed 15° head down with their arms supported at their sides. The operating field, including the neck area, was prepared with alcoholic chlorhexidine 0.5%. The vein was imaged using either a Site Rite device with 7.5 MHz probe (Dymax/Bard, Pittsburgh, PA, USA) or a SonoSite iLook device with a 5/10 MHz probe (SonoSite, Biggleswade, UK). The skin and subcutaneous tissues were infiltrated with lignocaine 0.5% 3040 ml with 1:200 000 epinephrine.
The vein and artery were imaged in cross-section together with the chest wall. An 18-gauge introducer needle was advanced at a steep angle towards the vein, guided by the orientation of the ultrasound probe (Fig. 1). The needle tip was seen as a moving bright spot associated with distortion of the tissues (Fig. 2). Gentle movements helped to identify the needle tip position. The tip was then seen indenting the vein wall. It was then either advanced into the vein or withdrawn if the vein was penetrated through both walls until blood could be aspirated freely into a syringe. The depth of the vein from the skin was calculated from measurements of the needle in situ with a sterile ruler. This was an approximation, as the needle was not perpendicular to the vein and was often moved slightly to facilitate threading the guidewire. We recorded the numbers of times the vein penetrated through both walls and contact with the rib cage occurred.
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We adjusted the catheter tip to lie at the junction of the right atrium and the superior vena cava. The length of the catheter could be changed by moving the anchoring cuff along its subcutaneous track. Any changes were recorded and the internal length of the catheter was calculated. The surface relations of the skin puncture site were measured from the clavicle (Fig. 3). These included the distance from the puncture site to the lower border of the clavicle and to an imaginary traditional landmark site for subclavian access. The latter was taken to be 1 cm below the junction of medial 1/3 and lateral 2/3 of the clavicle.
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Results |
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The axillary vein was seen with ultrasound in all patients but was considered unsuitable in four (Table 1). Axillary vein puncture and catheterization was successful in 194 of 196 patients, 153 on the right and 41 on the left. Cannulation was successful on the first, second and third needle pass in 76, 16 and 6% of the cases respectively. The internal jugular route was used, with ultrasound guidance, in the remaining six cases.
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Discussion |
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We did not perform a randomized control study comparing landmark-guided subclavian vein puncture with ultrasound-guided axillary vein puncture because: (i) two of the operators had limited experience with the use of ultrasound; (ii) the patency of the axillary veins had to be assessed before venepuncture in patients who had already had long-term subclavian catheters; (iii) we already used ultrasound to locate veins either routinely or if blind puncture of subclavian vein proved difficult, and we were reluctant to use blind cannulation; and (iv) complication rates are low, such as pneumothorax (12%) and arterial puncture (3.4%),12 when landmark methods are used by experienced operators. A very large trial would be needed to have adequate power to prove a benefit from the use of ultrasound.
The frequency of complications in this study was low and compared favourably with previous landmark-guided studies, despite inexperience of two of the operators in this technique.12 The frequencies of guidewire and catheter misplacement (15.5 and 12.9% respectively) are similar to those in other reports of subclavian access (15%).12 This is a limitation of both techniques unless fluoroscopy is used.
The ultrasound-guided axillary approach offers a number of potential advantages over landmark subclavian techniques. The anatomy favours ultrasound guidance and less complications. Manual compression of the axillary artery or surgical access is possible if arterial damage is caused. The puncture site is further away from potential sources of infection in patients with tracheostomy, central chest wall burns or sternotomy wounds.
Some patients will be unsuitable for this approach because of variation in anatomy.7 We found that axillary vein puncture is more difficult in obese patients, where the vein is deeper and may be beyond the range of higher-frequency ultrasound probes. Deeper veins may cause a difficult angle for the guidewire, dilators and catheters to traverse. A repeat puncture with the needle at a less acute angle to the vein may be required to facilitate passage of guidewires and catheters centrally. In this series the mean length of catheter inserted from the skin puncture site (21.4 cm on the right and 24.6 cm on the left) gives guidance for this route of access and is longer than typically used for the subclavian or internal jugular routes.
In conclusion, axillary vein puncture guided by ultrasound is a useful alternative to the landmark-guided subclavian approach for central venous access, and may cause less complications.
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Footnotes |
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References |
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