© The Board of Management and Trustees of the British Journal of Anaesthesia 2004
CORRESPONDENCE |
Ultrasound imaging of the axillary vein—anatomical basis for central venous access
Editor—We read with interest Galloway and Bodenham's excellent paper describing the anatomical and ultrasound basis for axillary vein cannulation.1It is true that compared with the subclavian route there is likely to be a much lower incidence of pneumothorax, haemothorax and chylothorax with the ultrasound guided axillary approach. It is also true that in certain situations, the axillary approach may provide the only source of central venous access: for example, in severely burned patients.2
We feel, however, that the risks to local structures, notably the brachial plexus, and the increased risks of significant venous thrombosis and stenosis, make the axillary approach to central vein access comparatively less attractive than other forms of peripherally based central venous access, for example PICC or femoral vein lines.1 Routine use of axillary venous cannulation may also reduce the treatment options available to particular patient groups, notably for individuals requiring formation of arteriovenous fistulae for haemodialysis.
In the light of recent guidelines governing the use of ultrasound for central line insertion,3 and in the limited instances where axillary central line insertion may be indicated, Galloway and Bodenham's1 accurate description of the ultrasonic appearance will be of undoubted value. We would, though, urge careful patient selection.
1 East Grinstead 2 Oxford, UK
Editor—Thank you for the opportunity to respond to these comments. We agree that careful patient selection is important in respect of choice of site of venous access. We suggest that the infraclavicular axillary vein approach is a useful route when a subclavian approach is indicated. The risks of infraclavicular axillary vein puncture in terms of thrombosis and brachial plexus injury are likely to be similar to traditional subclavian approaches. The approach, used clinically, only moves a few centimetres laterally, and depending on the angle of approach of the needle the vein may be punctured at the junction of the axillary and subclavian vein.
All routes of access have inherent advantages and disadvantages and it is up to the clinician to minimize the risk to an individual patient. A case series outlining this route of access has now been published in the BJA.4
Leeds, UK
References
1 Galloway S, Bodenham A. Ultrasound imaging of the axillary vein—the anatomical basis for central vein access. Br J Anaesth 2003; 90: 589–95
2 Andel H, Rab M, Felfernig M, et al. The axillary vein central venous catheter in severely burned patients. Burns 1999; 25: 753–6[Medline]
3 National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technological Appraisal Guidance 2002; 49, www.nice.co.uk
4 Sharma A, Bodenham AR, Mallick A. Ultrasound-guided infraclavicular axillary vein cannulation for central venous access. Br J Anaesth 2004; 93: 188–92
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||