Cephalic vein, access

FIGURE 45-1. The predominant types of vascular access for chronic dialysis patients are (A) the arteriovenous fistula and (B) the synthetic arteriovenous forearm graft. The first primary arteriovenous fistula is usually created by the surgical anastomosis of the cephalic vein with the radial artery. The flow of blood from the higher-pressure arterial system results in hypertrophy of the vein. The most common AV graft is between the brachial artery and the basilic or... 

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.)...

Dual-chambered pacing calls for the introduction of an atrial and ventricular electrode. The cutdown technique is less suited for this approach because all too often the cephalic vein can hardly acconunodate one electrode, and even less two. The percutaneous approach appears ideally suited for dual-chambered pacing as there is potential for unlimited access to the venous circulation. Various options for dual-chambered pacing venous access are listed in Table 4.10. There are four percutaneous approaches for dual-chambered pacing. 

Venous Cutdown of the Cephalic Vein Cephahc Venous Access... 

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. 

Venous access. In adnlt pacemaker practice, it is common to obtain a cut-down on the cephalic vein that will accommodate one or two leads. However, in children, becanse of the size of the vein, this is less likely. Still, the cephalic approach is preferable to the snbclavian approach, when available, as it completely avoids the complication of subclavian crush injury to the lead (39,40). Subclavian crnsh injnry resnlts from entrapment of the lead between the clavicle and the first rib, where it is subject to great stress with patient movement. 

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. 

Sigala F, Sassen R, Elissaios Kontis E, et al Surgical treatment of cephaUc arch stenosis by central transposition of the cephalic vein. J Vase Access 2014 15 272-277. 

PN can be administered via a smaller peripheral vein (e.g., cephalic or basilic vein) or via a larger central vein (e.g., superior vena cava). Peripheral PN (PPN) is infused via a peripheral vein and generally is reserved for short-term administration (up to 7 days) when central venous access is not available. PN formulations are hypertonic, and infusion via a peripheral vein can cause thrombophlebitis. Factors that increase the risk of phlebitis include high solution osmolarity, extreme pH, rapid infusion rate, vein properties, catheter material, and infusion time via the same vein.20 The osmolarity of PPN admixtures should be limited to 900 mOsm/L or less to minimize the risk of phlebitis. The approximate osmolarity of a PN admixture can be calculated from the osmolarities of individual components ... 

Blood and Urine Collection. As mentioned previously, serial blood samples can be fairly easily collected from the dog. The jugular vein is probably the most commonly used vein because of its size and accessibility. Other veins used less frequently are the cephalic, femoral, brachial, and saphenous. 

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. 

Local anesthesia and regional blocks, commonly used in vascular access surgery, may affect vein diameter and fistula blood flow rates, which are important predictors of fistula failure. Regional block anesthesia (brachial plexus block) is associated with vasodilation in both the cephalic and basilic veins and with increased fistula blood flow. 

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