Axillary vein puncture

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. 4.22 Axillary vein puncture and its relationship to surface landmarks as well as the first rib. (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.)...

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. 18.35 Posteroanterior chest radiograph from an elderly patient on dipyridamole and aspirin at the time of attempted implant in the left prepectoral region. Attempted venous puncture was complicated by axillary artery puncture and bleeding. The procedure was abandoned, and a pacemaker was placed several days later via the left axillary vein. However, on this posteroanterior radiograph obtained after the left-sided implant attempt, a very large hematoma was indicated by the marked soft tissue expansion on the left thorax. In addition, an area of greater opacity in the left prepectoral region is consistent with hematoma formation in the pectoral muscle and prepectoral tissues.

Biplanar superior or inferior cavograms are routinely obtained. Digital subtraction superior cavography is performed by simultaneous bilateral injection of 25 ml or more of a non-ionic contrast medium into the basilic or axillary veins. Inferior cavography is usually performed by bilateral femoral vein injection or retrograde caval catheterization from an arm vein. When puncture of the axillary or femoral vein is problematic due to edema, COj phlebography may be obtained by a peripheral injection of 50 ml of COj, which localizes a more proximal venous trunk for puncture. 

Using a rather unconventional puncture site for catheterization of the axillary vein, at the junction between the axillary and subclavian vein, trauma to the brachial nervous plexus is avoided, particularly when large-diameter catheters, serving for Gianturco stents for instance, are introduced (Dondelinger et al. 1991). As a general rule, venous stents should be placed sequentially, first in a distal position, then more proximally, in relation to the puncture site. When the confluence of the innominate veins is treated, the technique used depends on the anatomy and the type of stents required. Usually, the develop-... 

A man, aged 31, with thrombosis of the axillary vein was given an infusion of 750,000 units streptokinase in 12 hours after a loading dose of 250,000 units. One week after the infusion a hae-mothorax developed on the left side. The radiogram showed a broadening of the septum mediasti-nale, suggestive of mediastinal haematoma. After sternotomy the mediastinum proved to contain a haematoma the size of a fist, which was removed. From the thorax 1,700 ml blood was evacuated by puncture (8 ). 

The needle is inserted at an angle of 45 degrees parallel to the deltopectoral groove, l-2cm medial (Figs. 4.21 and 4.22).If the vein is not entered, fluoroscopy is then used to define the first rib. The needle is advanced and touches the first rib. Sequential needle punctures are walked laterally and posteriorly until the vein is entered. It should be noted that one cannot palpate the axillary artery pulse and, thus, it is not a reliable landmark. The axillary artery and brachial plexus are usually much deeper and more posterior structures. This simple technique using basic anatomic landmarks of the... 

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