Axillary venous access

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). 

Belott PH. Bhnd percutaneous axillary venous access. PACE 1998 21 873. 

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). 

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 lateral anterior axillary submuscular pectoral approach calls for creation of a dissection plane in the anterior axillary fold (104). A dissection plane is easily established as the pectoralis major is separated at the planes created between the pectoralis major and minor muscles. A skin incision is created inferiorly along the anterolateral axillary fold. It is carried down to the surface of the pectoralis major muscle. Both the pectoralis major and minor muscles are identified and separated and a plane of dissection is created between them. This approach usually requires a separate incision for venous access and tunneling to the axillary fold ineision. The inferolateral margin of the pectoralis major muscle is easily separated from the adjacent subcutaneous tissue for establishing a large plane of dissection. The ICD should be placed as medial as possible with the leads lateral to avoid the risk of CAN abrasion. With the ICD or pacemaker in the pocket, a careful multilayered closure is used. 

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. 

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