Axillary vein, access

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). 

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.)...

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... 

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). 

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.)...

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. 

When ultrasound guidance is used, a preliminary examination of the upper arm is performed to identify a suitable access vein. The basilic vein is the preferred site. The cephalic vein can be used,but is prone to spasm and has an acute angle as it joins the axillary vein. The veins are typically imaged in the transverse plane while the (echo-enhanced) needle is advanced (Fig. 6.4). The transducer is rocked cephalad and caudad keeping track of the needle tip. When this... 

The axillary vein can be accessed lateral to the junction of the first rib and clavicle. The cephalic vein can be accessed by a "cut-down" approach in the delto-pectoral groove. Some physicians believe both of these avenues of venous entry may be less likely to fracture due to trauma between the first rib and clavicle. 

For permanent cardiac pacing, physicians have always used the right chambers. In order to access to these anatomical regions, many different veins can be used, including the cephalic, axillary, subclavian, external or internal jugular, and the ile-ofemoral. 

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