Clavicle technique

A 67-year-old woman was provided with a totally implantable venous device in the right subclavian vein by the Seldinger technique with a peel-away sheath. The device was used for a course of chemotherapy. After about 1 month there was subcutaneous extravasation of the drug. A chest X-ray showed that the sihcone catheter had fractured below the clavicle and the distal portion of the catheter had embolized into the right atrium. The fragments were removed. 

This pinched-off effect appears to be due to narrowing of the catheter as it passes over the first rib and beneath the clavicle, when using the Seldinger technique, but it is usually only observed after long-term use. The authors recommended that the cephalic cut-down (Seldinger) technique is best avoided. 

Another venous lead implantation approach of historical interest is the jugular vein. The first method to acces the vein was nonpercutaneous, in which two incisions are required. The first skin incision, performed above the clavicle between the posterior rim of the sternocleidomastoid muscle and the anterior rim of the trapezius muscle, is necessary to reach the external jugular vein or, extended forward, the carotid sheath wherein internal jugular vein is present. A second infraclavicu-lar incision is then necessary to fashion the pocket over the pectoral muscle. Only the latter is required for the percutaneous approach, but regardless of the method used, in both cases, the lead must be tunneled to the pocket (usually over the clavicle). These techniques have been abandoned due to frequent complications related to lead failure. Outside the vein, the lead must run at an acute angle to reach the pocket, which is the reason for the recurrent lead fracture related to this venous approach. However, this is probably the better approach in case of lead extraction. 

One solution is to use a telescopic technique with progressively larger sizes to enlarge the costoclavicular route. Therefore, because the subclavian vein is compressed between the clavicle and anterior scalene muscle when the shoulder is displaced posteriorly and downward, it is advantageous to have the shoulder in neutral position with no roll during sheath advancement to keep the vein wide open. When sheath advancement is not possible or unsuccessful despite using the telescopic technique, and if the lead is free from adhesions, the Pisa approach [32] may be helpful. 

The clavicle may be elevated or depressed at the sternal end. The techniques described are for an elevated clavicle. 

FIG. 88-9 Articulatory technique for an elevated clavicle, patient seated. 

Various forms of lymphatic pump or thoracic pump will aid in improving venous and lymphatic flow as well as favorably affecting arterial circulation. Rib-raising techniques may be used to free bronchial secretions so they may be more easily expectorated and to normalize sympathetic innervation to the lung. The workload of breathing may be decreased by improving the compliance of the thorax —that is by freeing the ribs, vertebrae, clavicles, and sternum to restore the intrinsic elastic forces in the thorax. 

The cervical spine should be treated, with attention given to the accessory respiratory muscles. The clavicles should be freed and any sternal restrictions, including the angle of Louis, treated. Upper extremity motion restriction may be found in chronic lung disease. Spencer techniques free the upper extremity range of motion... 

After the acute asthma symptoms have abated, or in between exacerbations, manipulative treatment may include direct or indirect (including articulatory) techniques to treat motion restrictions of the clavicles, cervical and thoracic spine, ribs, thoracic inlet, sternum, and thoracoabdominal diaphragm. Treatment of these areas may improve chest wall motion, thereby diminishing the work of breathing ultimately to the benefit of the asthmatic patient. 

---