HANDS ON How to access the axillary vein Peter Belott, MD From the Electrophysiology Department, Sharp Grossmont Hospital, La Mesa, California. The axillary vein has become a desirable structure for venous access for implantation of defibrillator and pacemaker leads because the vein is large, easily accessed, and can accommodate multiple leads. Furthermore, axillary vein access is not associated with problems accompanying subclavian vein access, including pneumothorax and subclavian crush syndrome.1,2 The axillary vein can be accessed by a variety of techniques, ranging from a blind percutaneous puncture to the use of sophisticated tools such as ultrasound. Its use for device implantation was first suggested by Byrd.3,4 Axillary venous approach usually involves a progression from simple to more complex techniques.5 The following discussion focuses on a technique that uses simple superficial landmarks and the first rib. This technique for axillary venous access has proved to be safe, expeditious, and time-effective. Superficial anatomy Fundamental to access of the axillary vein is a complete understanding of the local superficial and deep anatomy. The important superficial landmarks are the clavicle, coracoid process, and deltopectoral groove (Figure 1). These structures are easily palpated. Occasionally the axillary artery pulsation can be palpated in the superior aspect of the deltopectoral groove. If palpable, it helps define the location and course of the axillary vein, which runs medial and anterior to the artery. The coracoid process is the most prominent superficial landmark; it is a bony prominence easily palpated on the anterior shoulder. The deltopectoral groove is the crease in the anterior shoulder. It is formed by the lateral aspect of the pectoralis major muscle and the medial border of the deltoid muscle. The cephalic vein is found in the deltopectoral groove as it runs inferior to superior, joining the axillary vein. It often joins the axillary vein at a right angle (Figure 2). This explains the occasional difficulty encountered when passing a lead via the cephalic vein. The clavicle is an important structure, as the axillary Address reprint requests and correspondence: Dr. Peter H. Belott, 1625 E. Main Street, Suite 202, El Cajon, California 92021. E-mail address: [email protected] Figure 1 Relationship of the axillary vein to the pectoralis major and minor muscles, deltoid muscle, clavicle, and cephalic vein. vein is found in the infraclavicular space as it rolls over the first rib. Deep anatomy The axillary vein is a large venous structure that is the continuation of the basilic vein. It starts at the lower border of the teres major tendon and latissimus dorsi. The axillary vein terminates immediately beneath the clavicle at the outer border of the first rib, at which point it becomes the subclavian vein. The axillary vein is covered anteriorly by the pectoralis minor, pectoralis major muscles, and costocoracoid membrane. It is anterior and medial to the axillary artery and brachial plexus that it partially overlaps. At the level of the coracoid process, the axillary vein is covered only by the clavicular head of the pectoralis major muscle. It is at this point that the axillary vein receives the more superficial and lateral cephalic vein (Figure 3). 1547-5271/$ -see front matter © 2006 Heart Rhythm Society. All rights reserved. doi:10.1016/j.hrthm.2005.10.031 Belott Axillary Venous Access 367 Palpation After the patient is prepped and draped, the first step is to palpate the superficial landmarks of the coracoid process, deltopectoral groove, and clavicle. With knowledge of the superficial and deep anatomy, these three structures help define the usual location of the axillary vein. Palpating the structures also helps in planning the surgical incision. Occasionally the axillary artery can be palpated in the superior aspect of the deltopectoral groove and infraclavicular space. If the artery is palpable, it defines the location of the axillary vein, which runs anterior and medial to the artery. This enables orientation of the percutaneous needle to avoid an arterial puncture and facilitates successful entry into the axillary vein. Procedure Figure 2 A: Cephalic vein draining directly into the axillary vein just superior to the pectoralis minor muscle. B: Contrast venography of the axillary and cephalic vein. Although the axillary vein can be accessed blindly through the skin, it is recommended that a skin incision be performed first. This enables more precise location of the axillary vein by visualizing the deep anatomy of the deltopectoral groove and pectoralis major muscle. The skin incision is located at the level of, or just slightly below, the coracoid process and runs perpendicular to the deltopectoral groove (Figure 4). The incision is made just medial to the coracoid process in the middle of the deltopectoral groove and carried inferomedially in a direction perpendicular to the deltopectoral groove for approximately 2 inches. The incision is carefully carried down to the surface of the pectoralis major muscle. The pectoralis major muscle, deltopectoral groove, and deltoid muscle are visualized. The inframedial incision is preferred as opposed to an incision parallel to the deltopectoral groove because it allows for optimal visualization of the deep anatomy and allows for a more anteromedial pocket. Superiorly, the dissection is carried to the surface of the pectoralis major muscle and the Figure 3 Detailed anatomy of the anterolateral chest demonstrating the relationship of the axillary vein to the pectoralis major and minor muscles and surrounding structures. 368 Heart Rhythm, Vol 3, No 3, March 2006 Figure 4 Orientation of the incision line with respect to the coracoid process and deltopectoral groove. Note the incision line is perpendicular to the deltopectoral groove. clavicle. In essence, the superior edge of the incision is defined by the pectoralis major– clavicular junction. The surface of the pectoralis major muscle is clearly visualized superiorly under the edge of the incision. The incision is held open with a Weitlaner retractor, which is continuously repositioned for optimal exposure. The purpose of this dissection is to allow appropriate positioning of the percutaneous needle over the axillary vein as it is advanced through the pectoralis major muscle. Although the axillary vein can be accessed blindly through the incision with a needle puncture 1 or 2 cm medial and parallel to the deltopectoral groove at the level of the coracoid process, use of the first rib for orientation is recommended to avoid the rare but real incidence of pneumothorax. To access the axillary vein using the first rib, the image intensifier is pulled over to the incision and the first rib is identified. It usually is the most superior U-shaped rib (Figure 5). The ribs seen traversing medial to lateral in an inferior direction are posterior. Identifying the first rib fluoroscopically is critical because if the operator misinterprets a posterior rib as the first rib, a percutaneous stick will result in a pneumothorax or access to undesired cardiopulmonary structures. The first step in accessing the axillary vein using the first rib is to place the 18-gauge percutaneous needle and syringe on top of the pectoralis major muscle in the superior aspect of the incision. Using fluoroscopy, the needle tip is placed in the middle of the first rib (Figure 6). The angle of the syringe and needle is gradually increased as the needle is advanced through the pectoralis major muscle. The for- Figure 5 Radiograph demonstrating the location of the first rib. Arrowheads point to the anterior border of the first rib. ward motion of the percutaneous needle and syringe should be such that the tip of the needle is maintained fluoroscopically over the body of the first rib. To maintain first rib Figure 6 Radiograph of the needle over the first rib. The needle tip is maintained in this position as the needle and syringe are advanced. This is accomplished by increasing the steepness of the needle angle. Belott Axillary Venous Access Figure 7 Needle trajectory in relationship to the first rib. The superior needle is piercing the axillary vein. The needle tip is touching the first rib. The lower needle with a shallow angle runs the risk of entering an intercostal space, causing pneumothorax. orientation, a rather steep angle generally is required. Needle advancement is continued until the first rib is struck. In essence, this maneuver attempts to pin the axillary vein to the first rib (Figure 7 ). Once the first rib is touched, the needle and syringe are slowly withdrawn under suction until the vein is entered, as indicated by a flash of blood in the syringe. If the first pass is unsuccessful, the needle and syringe are moved either medially or laterally and the maneuver repeated until the vein is entered. Once the vein is entered, the guidewire is passed and the sheath applied per standard technique. If the needle is advanced toward the first rib through tissue or muscle without the needle tip visualized fluoroscopically directly over the first rib, the shallow angle may result in the needle passing between intercostal spaces, leading to a pneumothorax. It is recommended that a “figure-of-eight stitch” be applied above the needle puncture for hemostasis and the retained guidewire technique used for multiple lead placement.6 Occasionally, the axillary vein cannot be found or accessed by this technique. In this case, alternate approaches are recommended. The first is the use of radiographic contrast.7,8 Rarely, the axillary vein is found to be completely occluded or nonexistent, with collateralization from other 369 veins over the clavicle. If contrast can identify the axillary vein, it is simply accessed by placing the needle tip in the middle of the contrast. Once again, it is recommended that the first or second rib be used for needle tip orientation to avoid pneumothorax by inadvertently passing the needle through an intercostal space. An alternate approach, if available, is the use of ultrasound to visualize the axillary vein and artery. An ultrasound probe is placed through the incision on top of the pectoralis major muscle and used to identify the artery and vein. The vein usually is medial and nonpulsatile, and it collapses with inspiration. The needle is passed parallel to the probe through the pectoralis major muscle into the vein guided by direct visualization on the ultrasound screen. It is extremely important to understand the superficial and deep structural and fluoroscopic anatomy. The first rib is a key fluoroscopic landmark. Occasionally, axillary venous access by the approach described is unsuccessful; in this case, traditional cutdown techniques of the cephalic vein or percutaneous access of the subclavian vein are recommended. References 1. Fyke FE III. Infraclavicular lead failure: tarnish on a golden route. Pacing Clin Electrophysiol 1993;16:373–376. 2. Magney JE, Flynn DM, Parsons JA, Staplin DH, Chin-Purcell MV, Milstein S, Hunter DW. Anatomical mechanisms explaining damage to pacemaker leads, defibrillator leads, and failure of central venous catheters adjacent to the sternoclavicular joint. Pacing Clin Electrophysiol 1993;16:445– 447. 3. Byrd CL. Safe introducer technique for pacemaker lead implantation. Pacing Clin Electrophysiol 1992;15:262–267. 4. Byrd CL. Clinical experience with the extrathoracic introducer insertion technique. Pacing Clin Electrophysiol 1983;16:1781–1784. 5. Magney JE, Staplin DH, Flynn DM, Hunter DW. A new approach to percutaneous subclavian needle puncture to avoid lead fracture or central venous catheter occlusion. Pacing Clin Electrophysiol 1993;16: 2133–2142. 6. Belott PH. A variation on the introducer technique for unlimited access to the subclavian vein. Pacing Clin Electrophysiol 1981;4:43– 48. 7. Spencer WK III, Zhu DWX, Kirkpatrick C, Killip D, Durand JB. Subclavian venogram as a guide to lead implantation. Pacing Clin Electrophysiol 1998;21:499 –502. 8. Ramza BM, Rosenthal L, Hui R, Nsah E, Savader S, Lawrence JH, Tomaselli G, Berger R, Brinker J, Calkins H. Safety and effectiveness of placement of pacemaker and defibrillator leads in the axillary vein guided by contrast venography. Am J Cardiol 1997;80:892– 896.
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