How to access the axillary vein Peter Belott, MD HANDS ON

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.
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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.
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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
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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
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Tomaselli G, Berger R, Brinker J, Calkins H. Safety and effectiveness
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