Axillary vein

Twenty-five percent ofthrombophilic patients develop thrombosis at unusual sites resulting in cerebral venous thrombosis, mesenteric vein thrombosis, hepatic venous thrombosis, retinal vein thrombosis, purpura fulminans, splenic vein thrombosis, portal vein thrombosis, renal vein thrombosis, or axillary vein thrombosis. The thrombotic disorders may involve inflammatory factors that contribute to the vascular deficit. In addition, embolic events also play a role in the development of these thrombotic complications. 

Each subclavian vein is a continuation of the axillary vein and runs from the outer rim of the first rib to the medial rim of the anterior scalene muscle. Here the subclavian and internal jugular veins join inside the anterior edge of the superior thoracic opening and create right and left innominate veins behind the sternal manubrium. The vein usually has a pair of valves about 2 cm from its end. The heads of clavicles extend posteriorly into the superior thoracic opening, displacing the veins posteriorly from the sternum. Because of the anteroposterior slope of the superior aperture, the arteries are... 

According to some recommendations [36] if osmolarity of the infusion is higher than 500 mOsmol/1, administration should occur via a central venous catheter that is inserted in a vessel with high blood flow such as the vena subclavia, proximal axillary vein or superior vena cava. 

A thorough understanding of the venous anatomic structures of the head, neck, and upper extremities are imperative for safe venous access (Fig. 4.2) (41). The precise location and orientation of the internal jugular, innominate, subclavian, and cephalic veins are important for safe venous access (42). Their anatomic relation to other structures is crucial in avoiding complications. The venous anatomy of interest from a cardiac pacing and ICD point of view starts peripherally with the axillary vein (43). 

The axillary vein is a large venous structure that represents the continuation of the basilic vein. It starts at the lower border of the teres major tendon and... 

Fig. 4.2 Detailed anatomy of the anterolateral chest, demonstrating the axillary vein with the pectoralis major and minor muscles removed. (From Belott PH, Reynolds DW. Permanent pacemaker and cardioverter defibrillation implantation. In Ellenbogen KA, Kay N, Wilkoff BL, eds. Clinical cardiac pacing and defibriUation, 2nd ed. Philadelphia WB Saunders, 2000, with permission.)...

Fig. 4.3 Anatomic relationship of the axillary vein to the pectoralis minor muscle. The pectoralis major has been removed. Note the cephalic vein draining directly into the axillary vein at approximately the first intercostal space. (From Belott PH. Unusual access sites for permanent cardiac pacing. In Barold SS, Mugica J, eds. Recent advances in cardiac pacing Goals for the 21st century. Armonk, NY Futura Publishing, 1997, with permission.)...

Table 4.9 Venous structures for pacemaker lead insertion. Cephalic vein Axillary vein Subclavian vein Internal jugular vein...

If the cephalic vein is too small, further dissection may be carried proximally. In rare instances, dissection will actually be carried to the deeper axillary vein. Once exposed, the cephalic vein is freed from its fibrous attachments and O silk ligatures are applied proximally and distally (Fig. 4.8). Once adequate venous control has been obtained, a horizontal venotomy is made with an iris scissor or a 11 scalpel blade (Fig. 4.9). The vein should be supported at all hmes with a smooth forceps. Using mosquito clamps, forceps, or vein pick, the venotomy is opened and the electrode(s) introduced (Fig. 4.10). Once venous access has been achieved, the electrodes are positioned in the appropriate chambers using standard techniques. 

The cephalic vein, a conunon venous access site for pacemaker implantation, drains directly into the axillary vein just superior to the pectoralis minor. The axillary vein is an excellent site for venous access, but is usually not considered because it is a rather deep structure. The surface landmarks of note are the infraclavicular space, deltopectoral groove, and the coracoid process. 

The axillary venous approach was initially reported in 1987 by Nichalls as an alternate site of venous access for large central lines (67). Nichalls developed a technique from cadaver dissection by which he estabUshed reliable landmarks. He defined the axillary vein as an infraclavicular structure. In his technique, the needle is always anterior to the thoracic cavity, generally... 

Fig. 4.17 Nichalls sketch of the landmarks for axillary vein puncture. (From Belott PH, Byrd CL. Recent developments in pacemaker and load retrieval. In Belott PH. New perspectives in cardiac pacing implantation techniques, 2nd ed. Armonk, NY Futura Publishing, 1991, with permission.)...

Fig. 4.19 Deep (A) and superficial (B) anatomic relationships of the Magney approach to subclavian vena puncture. Point M indicates the medial end of the clavicle. X defines a point on the clavicle directly above the lateral edges of the clavicular/subclavius muscle (tendon complex). Rl. Point D overlies the center of the subclavian vein as it crosses the first rib. St, the center of the sternal angle Cp, coracoid process Ax, axillary vein star, costoclavicular ligament open circle with closed circle, costoclavicular ligament open circle with closed circle inside, costoclavicular ligament sm, subclavius muscle. The arrow points to Magney s ideal point for venous entry. (Magney JE, Staplin DH, Flynn DM, et al. A new approach to percutaneous subclavian venipuncture to avoid lead fracture or central venous catheter occlusion. Pacing Clin Electrophysiol 1993 16(11) 2133-2142, with permission.)...

Fig. 4.24 Doppler location of the axillary vein crossing the first rib. AV, axillary vein CCL, costo-clavicular ligament CL, clavicle P, Doppler probe Rl, first rib R2, second rib SCM, subclavius muscle SCV, subclavian vein. (From Fyfce FE. Doppler guided extralboracic introducer insertion. Pacing Cbn Electrophysiol 1995 18 (5Pt 1) 1017-1021, with permission.)...

Seldinger technique are used. Because this technique directly visualizes the axillary vein, it has been used with considerable success for both pacing and defibrillator electrodes. There have been no pneumothoraces. The technique can be carried out transcutaneously or through the incision on the surface of the pectoralis muscle. 

The axillary vein is becoming a common venous access site for pacemaker and defibrillator implantations, given the concerns of the subclavian crush and the requirement for insertion of multiple electrodes for dual-chambered pacing and a large complex electrode for transvenous nonthoracotomy defibrillation. There are now a number of reliable techniques for axillary venous access (Table 4.11). 

Given the recent interest in the axillary vein, it is recommended once again that the implanting physician become thoroughly familiar with the anatomy of the anterior thoracic wall, shoulder, and axilla. It is imperative that the physician visit the anatomic laboratory to refresh and review the regional anatomy and surface landmarks. 

Fig 4.26 A Complete absence of the axillary vein. (Note plexus of veins draining over the clavicle into the external jugular vein and subsequently the innominate vein.) B Totally obstructed axillary vein. 

Fig. 4.66 A Stylized Ulustratioii of axillary venipuncture using tbe guidewire as a landmark. B Radiograph of needle accessing the axillary vein using the guidewire as a landmark. (Shefer A, Lewis BS, Gang ES. The retropectoral transaxillary permanent pacemaker description of a technique for percutaneous implantation of an invisihle device. Pacing Chn Electrophysiol 1996 19(llPt 1) 1646-1651, with permission.)...

Axillary vein thrombosis Partial great vein obstruction Pulmonary embolism ... 

NichaUs RWD. A new percutaneous infraclavicular approach to the axillary vein. Anesthesia 1987 42 151. 

Ramza BM, Rosenthal L, Hui R, et al. Safety and effectiveness of placement of pacemaker and defibrillator leads in the axillary vein guided by contrast venography. Am J Cardiol 1997 80 892. 

Fig. 5 J Intracardiac Ultrasound for Vascular Access. Use of vascular ultrasound to gain access to the axillary vein can greatly facihtate left ventricular lead implantation by improving vascular access at the beginning of the procedure. Typical ultrasound probes have frequencies of 7.5 or 9 MHz (a). The higher frequency probes are better for access for more superficial vascular structures like those in the neck, whereas the lower frequency 7.5 MHz transducers permit acceptable imaging of the axillary, cephahc and portions of the subclavian veins. Ultrasound gel must be placed inside the plastic probe cover to gain acceptable images (b, Panel A). The plastic cover is secured with sterile rubber bands (b, Panel B). To differentiate to the axillary vein (V) from artery (A), gentle compression is applied to the vessels, causing the vein to collapse while the artery does not (c).

Vascular ultrasound has also greatly facilitated the implant process by easing axillary vein localization. Commercially available systems (Site Rite , Bard Access Systems, Salt Lake City, UT) include either a 9 or 7.5 MHz ultrasound probe to localize the axillary artery and vein. Differentiating the vein from artery is easily accomplished by compressing the structures with probe and noting which collapses more easily (Fig. 5.3). In patients with elevated right heart pressures, this same effect can be facilitated by having the patient inspire forcefully. 

Another approach is the placement of a catheter in the subclavian vein via the femoral vein, which may be used to perform a radiographic contrast injection for outlining the venous structures, and may also be left as a target for subclavian needle entry. The catheter is advanced far laterally to the junction between the subclavian and axillary veins, and the use of this as a target allows for a very lateral entry and thereby avoids the problem of subclavian crush injury to the leads (41). The use of such a catheter for angiograms will also identify venous abnormalities, such as a persistent left superior vena cava prior to creation of the pacemaker pocket. 

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