The Axillary Vein: An Alternative Approach for Percutaneous ... - Chest

The Axillary Vein: An Alternative Approach
for Percutaneous Pulmonary Artery
Catheterization*
Claude Martin, M.D.;Jean Pierre Auffray, M.D.; Pierre Saux, M.D.;
Jacques Albanese, M.D.; and Fran#{231}oLsGouin, M.D.
The adllary vein route was investigated prospectively for
percutaneous pulmonary artery catheterization in 79 patients
who underwent 83 attempts. Forty nine of these
patients were tracheostomized and under mechanical yentilation
and eight had hemostasis disorders. Successful
catheterization was achieved 74 times in the 79 patients.
Pulmonary artery was reached within 6 ± 2.1 mm after the
catheter was set in place in the axillary vein. Less than 1 mm
was needed in 53 cases. Puncture of the axillary artery was
noted in II patients without complication. No other significant
complication was noted following the punctures. Mean
duration ofcatheterizations was 3.6 ± 2 days. No septicemia
was related to the catheterization procedure. One thrombosis
of the axillary vein was noted, Catheterization of the
pulmonary artery via the axillary vein is safe, simple and
reliable and can represent an alternative method should the
use of other routes be unsuccessful.
theterization of the pulmonary artery (PA) with a
flow-directed, balloon-tipped catheter is a common
procedure before anesthesia for patients with
cardiac disease who undergo major surgery, or for
patients under intensive care.’ Successful placement
ofthe catheter requires reliable and safe entry into the
intrathoracic circulation. The vessels usually selected
include veins of the external jugular veins
(EJV),5’6 internal jugular veins (IJV),257’0 subclavian
veins (SCV)5” and femoral veins.su Some difficulties
can arise with each of these routes . The arm veins are
often in poor condition after several days of treatment
in the intensive care unit (ICU). Catheterization of the
PA via the femoral vein can be difficult without the
help of fluoroscopic guidance,’ a technique which is
not always available at patient’s bedside in the ICU.
Cannulation of the 1W or SCV is associated with a
number ofminor and some more serious complications
including arterial puncture and pneumothorax.’’4
Entry into the intrathoracic circulation via the axillary
vein (AV) is an alternative Clinical practice
fur several years supports the impression that PA catheterization
via the axillary vein is safe, reliable and
simp1e. In this study, the feasibility ofPA catheterization
using the axillary vein approach was investigated
prospectively in unanesthetized patients and in patients
under mechanical ventilation for treatment of
adult respiratory distress syndrome (ARDS).
MATERIAL AND METHODS
Seventy nine patients, 18 women and 61 men ranging in age from
6D#{233}partement d’Anesth#{233}sie-R#{233}animation Marseille-Sud, HOpital
Sainte-Marguerite, Marseille, France.
Reptint requests: Di Martin, Hopital St. Marguerite, 13099 Marseille,
France
18 to 75 years, were included in the study. They underwent 83
cannulations ofthe axillary vein and were carefully followed up in a
prospective manner during a 17-month period. Informed consent
was obtained from the 34 patients with angina who were scheduled
for elective surgical procedures.
There were ten women and 24 men ranging in age from 42 to 75
years, mean age 62 ± 2 years (mean ± SEM). Twenty seven of these
patients underwent abdominal aortic aneurysmectoiy. The other
seven patients underwent hepatic resection for malignant tumors.
All patients were catheterized in the operating room. Catheterizalion
ofthe PA was also performed in 45 patients with ARDS. Eight
women and 37 men ranging in age from 18 to 67 years, mean age
50 ± 3 years). For these sedated patients, informed consent was obtamed
from the family. All patients were tracheostomized and under
controlled mechanical ventilation with positive end-expiratory pressure
(PEEP) above 10 cmH2O. Ventilation with PEEP was used to
treat hypoxemia following bacterial pneumonia in 23 patients,
aspiration pneumoniain six, peritonitis in eight, fat embolism in five,
and viral pneumonitis in three. Eight patients had blood platelet
counts below 70,000 mm3 and four patients below 20,000 mm3.
The axillary vein was cannulated following an original approach.’
The patient lay supine, the arm to be cannulated was abducted away
from the patient side, and the hand placed behind the occiput. All
catheters were set in place using sterile technique including masks,
gowns, gloves and sterile draping. The axilla was shaved, cleansed
with an iodine solution (Betadine) and towelled. The operator stood
on the same side as the puncture site. The axillary artery was
palpated and its course was noted(Fig 1). After alocalanesthetic was
injected into the skin and subcutaneous tissues, the azillaryvein was
cannulated initially with a 20-gauge, 51 mm (2 inch) needle. The
needle was inserted high in the axilla at an angle of3O#{176} to the skin
parallel to the course ofthe artery, toward the chest wall and 1 cm
medial to the artery(Fig 1). Puncture ofthe axillaryvelnwas realized
higher in the axilla than with Spracklen’s method.’7 After the needle
was inserted into the vein, a 40-cm long, 0.64-mm (0.025 inch)
diameter straight guide wire was threaded with subsequent 8.0-
French dilator/sheath unit (Desilet, Vygon Laboratories) guided
over the wire, and 7.0-French PA catheter (93A-131 7 F, Edwards
Laboratories) inserted into the sheath. Fluoroscopic guidance was
never used in this study. Once the tipofthe PAcatheterwas setin the
superior vena cave., the balloon was inflated with 1.2 ml of air and
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FIGURE 1. Position of patient for axillary vein
catheterization. The lateral border of the pectoralis
majo muscle and the course of the
axillary vein are marked with a skin peflcil. The
axillary artery is palpated with the left hand.
pushed while the vascular pressure and the ECG were carefully
monitored.’3 Once the wedge pressure was obtained, the balloon
was deflated. Before the PA catheter was secured to the skin with a
suture, the arm was stretched out and put at an angle of3O#{176} with the
thorax. The pressure tracing was then carefully observed. If wedge
pressure appeared with an inflation volume of less than 1 ml, the
balloon was deflated and the catheter withdrawn centrally. With this
technique we insured that the catheter tip was located as centrally as
possible. Daily chest x-ray films were reviewed to check the position
of the catheter tip.
During placement of the PA catheters, careful monitoring of the
oscilloscope tracing was completed for signs of myocardial ischeinia
(angina or depression ofST-segment on the EGG ofi mm or greater),
premature ventricular contractions (PVCs), runs of ventricular
tachycardia (three of more successive PVCs) or any other arrhythmia.
Following catheter placement, puncture sites were
cleansed with Betadine solution; then a sterile gauze impregnated
with Betadine was applied to the site. Finally, the catheter and
sterile gauze were covered with a sterile occlusive dressing. An
adhesive, transparent, semipermeable film was used (Op-Site,
Smith and Nephew, mc). The 10-cm segment ofcatheter extending
from the puncture site was coiled within the dressing. Sterile
dressing changes were carried out every day, using the same
technique. Stopcocks and tubing were changed daily, using sterile
technique. These procedures were eventually performed several
times a day ifdressings were soiled or unstuck. Patients were visited
every day and puncture sites were inspected for hematoma and
evidence of infection (redness, swelling, heat). Cultures of the
catheters were obtained only when catheter-related infection, and
catheter-related bacteremia were suspected, or when puncture sites
became infected. Catheter-related infection was defined as follows:
temperatures38.5#{176}C, white blood cell count12,500/mm3, no
other apparent source ofinfection. Catheter related bacteremia was
defined as follows: species from catheter tip culture and from
separate blood culture obtained by venipuncture identical, no other
source of bacteremia, temperature38.5#{176}C, white blood cell
count12,500/mm3. In all patients, blood cultures were obtained
when body temperature was38.5#{176}C. Body temperature was
checked every four hours. The catheters were aseptically removed
by intensive care nurses. The insertion site was cleaned with an
iodine solution and the distal 3 cm of the catheter cut off with a
scalpel blade. In the laboratory, catheter segment was transferred
from a transport tube (Culturette, Marion Corp) onto the surface of
blood agar plates. Growth of 15 or more colonies on a semiquan-
titative plate was regarded as positive, indicating catheter infection.
In the other patients, when no catheter-related infection or bacteremia
were suspected, the cultures of catheter tip were not
obtained.
RESULTS
Axillary vein catheterization for placement of a PA
catheter was attempted 83 times in the 79 patients. A
total of 74 catheterizations were successful (89.2 percent).
The right axillary vein was utilized 36 times and
the left axillary vein 47 times. In six cases (7.2 percent),
the operator failed to catheterize either axillary vein
and in three cases (3.6 percent) the guide wire could
not be successfully introduced into the vein. Therefore,
of the 74 cases in whom the PA catheter could be
introduced into the axillary vein, 74 (100 percent)
underwent successful PA catheterization. This required
less than three punctures in 53 cases (64 percent).
The time necessary to perform the cannulations
was 13 ± 2 mm (range: 25 sec to 45 mm). The time required
to reach PA was 6 ± 2. 1 mm after the tip of the
catheter was inserted into the vein. In 53 cases (64 percent)
the PA was reached within 1 mm or less. The
entire PA catheterization procedure was 18 ± 3 mm in
the 74 cases in whom PA was catheterized successfully.
In five cases (6 percent) ventricular extrasystoles were
observed, but none ofthe patients exhibited ventricular
tachycardia. No patient experienced angina or
EGG changes. Arterial punctures occurred 11 times (13
percent) and large hematomas were always avoided by
prolonged pressure (3 mm or more) very easily
achieved because of the superficial position of the
axillary artery. No other complication was noted. The
catheters were in place for 2. 1 ± 1. 5 days in patients
undergoing surgery and for 4. 6 ± 1. 5 days in patients
with ARDS. No septicemia or bacteremia was related
to the PA catheterization. In the ARDS group, five
cases of catheter-related infection were suspected.
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Catheters were withdrawn and cultures of the tips
showed Staphylococcus aureus in three cases, Proteus
mirabilis in one case, and Pseudomonas maltophilia in
one case. Blood cultures obtained from these patients
did not grow any organism. One thrombosis (1.2
percent) of the axillary and subclavian vein was
clinically diagnosed and successfully treated with
heparin. No late neurologic sequel and no damage of
the axillary plexus were noted.
DISCUSSION
Placement of a PA catheter requires entry into the
intrathoracic circulation. The central vessels can be
reached percutaneously from several sites. Catheterization
of the deeper venous route (IJV or SCV) is
associated with serious complications such as arterial
puncture, pneumothorax or accidental entry ofthe PA
catheter into the mediastinum.’’4 An approach via
the antecubital vein is safer,3 but catheterization of this
vein is often impossible in patients after several days of
hospitalization, especially in the ICU. Puncture of the
EJV is also simple and safe,6#{176}but the vein is not present
in all patients. Catheterization ofthe AV can be an
alternative
method.
In this study, PA catheterization was achieved in 89.2
percent of attempts. This success rate is lower than
with the IVJ which is the vessel most often selected fbr
entry into the intrathoracic circulation.29”#{176} Cannulation
ofthe AV is proposed as an alternative route for PA
catheterization and must be compared with other alternative
routes. The 89.2 percent success rate of AV
compares favorably with the 77 percent success rate
reported for EJV by Schwartz et al,6 with 48 percent of
the patients catheterized after two or less cannulation
attempts. This 89. 2 percent success rate of AV also
compares favorably with the 75 percent reported for PA
catheterization via the antecubital vein.3 The time of
catheter insertion via the AV seems acceptable. Cannulation
of the AV is perfurmed within a few minutes
and needs less than three cannulation attempts in 64
percent. In a few cases, more time was needed for AV
cannulation. This was related in most cases to procedures
performed by residents during their first year of
training. As with other vein routes, procedures perfurmed
with more skilled and experienced operators
are considerably more rapid. Malposition of the arm
can lead to some difficulties in AV cannulation. Should
this occur, it is of great importance to place the hand
correctly behind the occiput before a new puncture is
attempted. There are no controlled studies to compare
the time required to achieve the entire procedure of PA
catheterization via AV and other routes. However, this
time averages 15 mm using IJV and 21 mm using
basilic vein.3 In this study, the time needed was 18 ± 3
mm, which is acceptable. Arterial puncture occurred
at a similar frequency as during IJV puncture.7’#{176}’4#{176} No
complication was noted fullowing these arterial punctures.
They were all easily treated with finger pressure
enhanced by the superficial position of the artery. No
pneumothorax followed the PA catheterization. The
risk ofneurologic sequel after puncture ofthe nerves of
the arm or forearm seems more theoretic than real. No
complication ofthat kind was noted. This is confirmed
by Spracklen et al’7 and by a study based on over 300
cannulations over several years.’
A low incidence of ventricular dysrhythmias was
observed in this study (6 percent). Frequency of this
complication is highly variable, ranging from 72 percents
to 10 percent.3 In our study, cardiac monitoring
was done using oscilloscope tracing and not paper recording.
Should the latter technique be used, the
incidence of dysrythmias could have been higher. In
six cases, chest x-ray films obtained daily allowed
diagnosis of spontaneous inward migration of the
catheter which was withdrawn to a proper position. No
kinking in the AV was noted. One thrombosis ofthe AV
was diagnosed. In this study, only clinical signs were
used to investigate this complication and we cannot
exclude that routine use of phlebography might have
shown a greater incidence of thrombosis of the AV.
Catheter-related sepsis can cause serious nosocomial
infections. No case ofcatheter-induced bateremia was
noted in our patients (all of them had blood cultures
drawn when body temperature was38.5#{176}C). Catheter-related
infection was suspected in five cases (6
percent). Resolution ofthe infection was obtained in all
cases after catheter removal. Catheter tip cultures
were not obtained in all the patients, but only when
clinical features were consistent with local or general
catheter-related sepsis. For this reason, we cannot
exclude that positive-catheter cultures (growth on the
blood agar), without local or general infection, might
have been present in some of our patients. This
incidence ofcatheter-related sepsis was comparable in
a previous study of more than 300 AV cannulations
where septicemia occurred in 2.7 percent of the
patients.’8 These patients were at risk of catheterrelated
infection since most of them were tracheostomized
and average duration ofcatheterization was 18.6
days.’8
As a practical point, the administration of medications
through a distal vein in the catheterized arm
should be discouraged. This study does not provide
controlled data about this point, but venous stagnation
might occur following AV cannulation and cause elevated
drug concentrations and tissue slough.
It is concluded that PA catheterization is performed
easily, reliably and relatively free from complications
via the AV. This technique represents an alternative
method ofPA catheterization which may have merit in
certain patients in case of inability to use the other
sites.
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