A Modified Internal Jugular Vein Access for Long-Term Catheter Placement in Cancer Patients

Background Placement, handling, and maintenance of indwelling central venous access devices may be difficult due to anatomical, clinical, or hematologic conditions in many cancer patients needing chemotherapy. An alternative approach technique is suggested joining surgical dissection to venipuncture, assisted by fluoroscopy, as a secure way to avoid complications of long-term indwelling catheters. Although ultrasound guided puncture is a safe procedure, it is not always available or familiar to most surgeons. Methods At the National Cancer Institute (INCA) in Rio de Janeiro, Brazil, 1750 long-term catheter placements were performed between the years 1997 and 2005. Among those, 160 were done through an alternative technical procedure consisting of an anterior cervical cutdown approach to the internal jugular vein (IJV) followed by percutaneous visual puncture of the vein. This modified internal jugular vein access (MIJVA) was employed when other access techniques were not feasible or if other underlying conditions increase the risk of bleeding complications. Results The MIJVA procedure was successful in all 160 patients. Although it was used only as an exceptional option in difficult venous accesses, further prospective trials must be conducted, however, for comparison with other technical approaches. Conclusion The MIJVA is an option that provides successful IJV dissection and safe percutaneous visual puncture overcoming anatomical pitfalls in placement of long-term venous access for chemotherapy in cancer patients.     

Ultrasound-guided infraclavicular axillary vein cannulation

Background and objectivePercutaneous central venous cannulation is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. We wanted to evaluate an ultrasound-guided technique for the axillary vein cannulation, looking specifically at the ease of use, success rate and decreased complications.MethodsSixty consecutive surgical patients scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding an in plane puncture of axillary vein was used. After locating the vessels, an echo-guided sterile procedure was performed to cannulate the vein.ResultsCannulation was successful in all patients, and there were no complications during insertion of the catheters. Both axillary veins were cannulated, and the vein was punctured successfully at first attempt in 95% of the patients. The median time from the start of the first puncture (of the skin) until the aspiration of blood was 15 (7– 135) seconds.ConclusionThis ultrasound-guided technique for inserting central venous catheters in axillary vein was easy to apply. This procedure could increase precision and safety in patients undergoing axillary vein cannulation.     

Ultrasound-guided infraclavicular axillary vein cannulation for central venous access

Background. Infraclavicular axillary vein cannulation is notcommonly used for central venous access because identifyingthe surface landmarks is difficult. Ultrasound guided axillaryvein puncture has not been well described. We assessed ultrasoundimaging to guide catheterization of the infraclavicular axillaryvein. Methods. In 200 consecutive patients we attempted to catheterizethe axillary vein using ultrasound imaging. After successfulvenepuncture, a tunnelled Hickman line was inserted for long-termcentral venous access. Surface landmarks of the skin puncturesite were measured below the clavicle. We measured the depthof the vein from the skin, the length of the guidewire fromskin to carina and the final length of catheter that was inserted. Results. The axillary vein was successfully punctured with thehelp of ultrasound imaging with first needle pass in 76% ofpatients. The axillary vein was catheterized successfully in96% of the cases. Guidewire malposition was detected and correctedby fluoroscopy in 15% of cases. Complications included axillaryartery puncture in three (1.5%) and transient neuralgia in two(1%) cases. Conclusion. Ultrasound-guided catheterization of the infraclavicularaxillary vein is a useful alternative technique for centralvenous cannulation with few complications.      

Ultrasound-guided regional anesthesia for upper limb surgery

Purpose

The purpose of this module is to review the main ultrasound-guided approaches used for regional anesthesia of the upper limb.

Principal findings

The anatomical configuration of the upper limb, with nerves often bundled around an artery, makes regional anesthesia of the arm both accessible and reliable. In-depth knowledge of upper limb anatomy is required to match the blocked territory with the surgical area. The interscalene block is the approach most commonly used for shoulder surgery. Supraclavicular, infraclavicular, and axillary blocks are indicated for elbow and forearm surgery. Puncture techniques have evolved dramatically with ultrasound guidance. Instead of targeting the nerves directly, it is now recommended to look for diffusion areas. Typically, local anesthetics are deposited around vessels, often as a single injection. Phrenic nerve block can occur with the interscalene and supraclavicular approaches. Ulnar nerve blockade is almost never achieved with the interscalene approach and not always present with a supraclavicular block. If ultrasound guidance is used, the risk for pneumothorax with a supraclavicular approach is reduced significantly. Nerve damage and vascular puncture are possible with all approaches. If an axillary approach is chosen, the consequences of vascular puncture can be minimized because this site is compressible.

Conclusions

Upper limb regional anesthesia has gained in popularity because of its effectiveness and the safety profile associated with ultrasound-guided techniques.     

老年患者超声引导下锁骨下静脉与腋静脉穿刺的比较

目的比较老年患者超声引导下锁骨下静脉与腋静脉穿刺置管的效果。方法需要放置中心静脉导管的患者99例,男68例,女31例,年龄65岁,随机分为两组:锁骨下静脉穿刺组(SV组,n=49)和腋静脉穿刺组(AV组,n=50)。记录锁骨下静脉和腋静脉超声定位时间、静脉深度、静脉最大内径,计算静脉塌陷率。记录深静脉一次穿刺成功、二次穿刺成功、总穿刺成功例数和穿刺时间。记录误穿动脉、气胸等并发症的发生情况。结果与AV组比较,SV组超声定位时间明显缩短(P0.01),静脉深度、静脉最大内径明显增大(P0.01),呼吸塌陷率明显降低(P0.01),一次穿刺成功率和总穿刺成功率明显升高(P0.05)。两组二次穿刺成功率、穿刺时间差异无统计学意义。两组均无误穿动脉、气胸等并发症。结论老年患者超声引导下锁骨下静脉穿刺较腋静脉穿刺成功率高。     

Catheter-related infections following axillary vein catheterization

Background : The aim of this study was to determine the rate of infectious complications following axillary vein cannulation and a compare to that observed after internal jugular vein cathterization.
Methods : A prospective comparative open study was carried out to determine the rate of infectious complications related to the use of catheters inserted via the axillary vein or the internal jugular vein. During the study period all patients submitted to central venous catheterization were evaluated. A total of 141 patients entered and completed the study. Catheter insertion sites were either the axillary vein punctured in the axilla, or the internal jugular vein punctured using an anterior approach. Catheter tips were cultured using a quantitative technique. Clinical information pertaining to the analysis was prospectively collected.
Results : A total of 141 catheters from 141 patients entered was studied. Clinical characteristics and risk factors for catheter infection were similar in both groups. The incidence of catheter-related infection (including catheter-related sepsis, and bacteremia) was not different between the two groups (axillary vein: 8.1%; internal jugular vein: 7.6%). Catheter-related bacteremia were seen at a rate of 3.7% in the internal jugular vein group and a rate of 1.6% in the axillary vein group (NS). The incidence of catheter colonization was similar in both groups (axillary vein: 14.5%; internal jugular vein: 11.4%).
Conclusion : Catheter-related infection after axillary vein catheterization was similar to that observed after internal jugular vein catheterization. The chance of developing catheter-related sepsis was less than 10% with either route when catheters were used for the treatment of severely ill patients.     

Real-time in-plane ultrasound-guided supraclavicular approach to subclavian vein cannulation in cardiac surgery: An underused approach

BackgroundAlthough the subclavian vein has several anatomical advantages; it has been underused in cardiac surgery. In this feasibility study, the author aimed to test real-time in-plane ultrasound-guided supraclavicular subclavian vein cannulation during elective cardiac surgical procedures as an acceptable alternative for the routinely used internal jugular vein.MethodsThis prospective feasibility study included forty adult patients undergoing elective on-pump cardiac surgical procedures performed during the period from June 2012 to January 2013. The aim of this study is to test real-time in-plane ultrasound-guided supraclavicular subclavian vein cannulation in terms of time of placement, number of attempts to puncture the vein, inadvertent arterial puncture, usability before and after sternal retractor expansion, and catheter tip position.ResultsSuccessful cannulation of the subclavian vein was accomplished in an average time of 43.8 (14.9) s. The median number of skin punctures was 1 (range 1–3). All lumens of the catheters were usable both before and after using the sternal retractor in all cases except one. The central venous pressure waveform has been recorded in all cases except one. Using transesophageal echocardiography all catheter tips were found to lie within 1.6 cm from the crista terminalis.ConclusionReal-time in-plane ultrasound-guided supraclavicular subclavian vein cannulation is an easy and safe approach to be used in adult patients undergoing cardiac surgical procedures.     

Endoscopic axillary exploration and sentinel lymphadenectomy

Background: Minimally invasive approaches have changed the practice of surgery in several specialties. The purpose of this study was to develop a reproducible endoscopic technique for the evaluation of the axilla in breast cancer patients. Methods: A total of 23 patients with biopsy-proven breast carcinoma were enrolled. Patients were positioned in the supine position with the ipsilateral arm abducted at 90°. A 1-cm skin incision was made at the superior aspect of the axilla. Dissection was carried bluntly to the lateral border of the pectoralis major. A balloon distention device was inserted into the tract and distended under endoscopic vision to create a working space. Insufflation was initiated up to a pressure of 8 mmHg. A 30° laparoscope was introduced for visualization of axillary contents. One or two additional 5-mm cannulas were placed as needed under direct visualization. Manipulation of axillary contents was performed, and in 19 patients a sentinel node identification technique was applied. Results: In all patients, using insufflation and minimal instrument dissection, the axillary vein, long thoracic, and thoracodorsal nerves were found in their usual anatomical locations. Utilizing blunt and sharp dissection, the axilla was thoroughly inspected, and individual lymph nodes were easily identified and extracted. In 11 of 19 patients, a sentinel node or blue dye was identified using isosulfan blue. There was a procedure concordance of 84%, and there were no complications. Conclusions: We describe a novel endoscopic technique for the evaluation of the axilla in breast cancer patients. This technique allows (a) creation of a minimally invasive working space within the axilla, (b) recognition of key axillary anatomic landmarks, and (c) instrument manipulation within the axilla to identify and extract lymph nodes, and apply the sentinel node technique. This is the first report of a minimally invasive approach to axillary exploration to employ sentinel lymph node mapping. Received: 22 April 1996/Accepted: 15 May 1998     

Repair of the upper eyelid by means of the prepuce after severe burns

Burns to the eyelid often constitute difficult problems for reconstruction or repair. Functional and aesthetic aspects have to be considered, and suitable donor sites are not readily available in severely burned patients. In male patients, the prepuce yields an almost ideal skin for eyelid repair because of its high elasticity and adequate texture. Two patients with repair of both upper eyelids using the prepuce are demonstrated. The color match of this skin graft is satisfying. If both layers of the prepuce are transplanted, they yield enough tissue to cover both upper eyelids. This method seems to be an adequate method of reconstruction of burned eyelids in severely burned male patients when the usual donor sites for skin grafts are not available.     

Real‐time ultrasound‐guided axillary vein cannulation in children: a randomised controlled trial

The axillary vein is a good site for ultrasound‐guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real‐time ultrasound‐guided axillary vein cannulation with conventional infraclavicular landmark‐guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound‐guided axillary vein (axillary group) or landmark‐guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first‐attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25–6.48, p = 0.010). The first‐attempt success rate was 46% for the axillary group and 40% for the landmark group (p = 0.274) and median time to cannulation was 156 s for the axillary group and 180 s for the landmark group (p = 0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p = 0.08). We conclude that axillary vein cannulation using a real‐time ultrasound‐guided in‐plane technique is useful and effective in paediatric patients.     

保留肋间臂神经乳腺癌腋窝清扫术85例

目的：探讨乳腺癌腋窝清扫术保留肋间臂神经的临床意义。方法：在85例乳腺癌腋窝清扫术中，采用腋静脉下方途径保留肋间臂神经，术后观察其效果。结果：84例保留肋间臂神经成功，1例不慎切断。术后上臂内侧感觉异常发生率为4．7％(4／85)，2周后症状消失。随访均未发现局部复发。结论：乳腺癌腋窝清扫术中保留肋间臂神经，可明显减少上臂内侧感觉障碍的发生率，有利于提高患术后生活质量。     

Anterolateral thigh perforator flap from previously burned skin for secondary reconstruction of neck with post burn sequelae, new limits explored.

We report the use of anterolateral thigh perforator flap (ALTF) from previously burned skin for reconstruction of burn cervical contracture. At the time of treatment, there are no reports of the use of perforator flaps from previously burned skin. We have used this technique and feel that it might be an option to consider in view of the fact that massively burned patients often have limited donor site availability, despite requiring flap tissue to resurface difficult anatomical regions.     

Alternative puncture site for implantable permanent haemodialysis catheters

BACKGROUND.: Vascular access represents a major problem in long-term haemodialysispatients. In patients without patent internal arteriovenousfistula, the implantation of cuffed catheters to provide a temporaryor permanent central venous access is often necessary. Catheterizationof the subclavian vein should be avoided because of the highrisk of stenosis or thrombosis. The puncture of the internaljugular vein can be impossible in cases with stenosis or thrombosisdue to previous catheterization. To overcome these limitationswe evaluated an alternative puncture site for implantation ofpermanent central venous catheters. METHODS.: The very low, most central jugular approach, first describedby Rao et al., with the site of puncture just above the medialnotch of the clavicle, was used to introduce Dacron cuffed dialysiscatheters into the innominate vein in four chronic dialysispatients with impeded conventional vascular access. RESULTS.: In all four patients puncture of the internal jugular vein usingRao's technique was successful at the first attempt. All fourcatheters were introduced without any problems. Even in a casewith thrombosis of the internal jugular vein and the ipsilateralsubclavian vein, this technique was successfully applied. Nocomplications such as haematoma, pneumothorax, or catheter-associatedinfection were observed. The catheters remained in situ for2–12 months with excellent blood flow and without clinicalevidence of venous stenosis or thrombosis. CONCLUSIONS.: In case of failure to cannulate the internal jugular vein bya conventional approach, the technique of Rao et al. can beused before sacrificing the subclavian vein or changing to exotictechniques such as translumbar, transfemoral or transhepaticmethods.     

Ultrasound imaging of the axillary vein--anatomical basis for central venous access

Background. The central veins that are usually cannulated arethe jugular, subclavian, femoral and brachial. If subclaviancatheterization is difficult using surface landmark techniques,we now use ultrasound to catheterize the infraclavicular axillaryvein. This approach is not widely used and the ultrasound appearancehas not been formally described. We examined the anatomicalrelationships of the axillary vessels to guide safe cannulationof the axillary vein. Method. In 50 subjects, we used ultrasound to examine the infraclavicularregions from below the mid-clavicular point and at 2 cm and4 cm further laterally (described as the middle and lateralpoints) with the arms at 0°, 45° and at 90° abduction.We took measurements at each point, with the artery and veinseen in cross-section. The depth from the skin, vessel diametersand the distance between the vessels was measured. The amountof overlap was scaled from 0 (no overlap) to 3 (complete overlap).We also recorded (if visible) the distance between the rib cageand axillary vein. A longitudinal image of the vein was alsoobtained. Angle of ascent (in relation to the skin), lengthand depth of the vein was measured. Results. Axillary vessels were seen in 93% of images. The meandepth from skin to vein increased from 1.9 cm (range 0.7–3.7cm) medially to 3.1 cm (1.1–5.6 cm) laterally. The venousdiameter decreased from 1.2 cm (0.3–2.1 cm) medially to0.9 cm (0.4–1.6 cm) laterally. The arterio–venousdistance increased from 0.3 cm to 0.8 cm. Median arterio–venousoverlap decreased from 2/3 (mode 3/3) to 0 (0). The distancefrom rib cage to vein increased from 1.0 cm to 2.0 cm. Conclusion. The axillary vein is an alternative for centralvenous cannulation and we present an anatomical rationale forits safe use. Less arterio–venous overlap and a greaterdistance between artery and vein and from vein to rib cage shouldprovide an increased margin of safety for central venous cannulation. Br J Anaesth 2003; 90: 589–95     

Cathétérisme percutané rétrograde de la veine jugulaire interne chez les traumatisés crâniens

The monitoring of jugular venous oxygen saturation and lactate concentration in order to detect cerebrallschaemia or hyperaemia requires the Insertion of a fibreoptic catheter into the upper bulb of the internaI jugular vein. With dissection studies we have defined superficial anatomical landmarks which are constant and easily palpable, namely the mastoid process and the sternocleldomastoid muscle. This technique does not require a rotation of the head. The puncture site is located at the top of a triangular area between ifs sternal and clavicular insertions. At this site the jugular vein is rather superficial. This study reports our experience of the retrograde catheterlsation of the jugular veln in twelve severely head injured patients.     

Central Venous Access via External Jugular Vein with CT-Venography Using a Multidetector Helical 16-Section CT

ABSTRACT

Objective: To determine the success rate and complications of using the external jugular vein (EJV) for central venous access with a preoperative estimate of the detailed anatomical orientation of the cervical venous plexus using computed tomography venography (CT-V). Design: Prospective, observational human study. Setting: Surgical intensive care unit. Patients: Fifty-two patients who were undergoing EJV cannulations with CT-V using a Multidetector Helical 16-section CT (MDCT). Intervention: The preoperative anatomical estimation of the cervical venous plexus was performed with CT-V using an MDCT. In particular, the angulation between the EJV and the right subclavian vein (SCV) was measured. The anatomical abnormalities and the angulation between the EJV and the anterior jugular vein (AJV), transverse cervical vein (TCV), and suprascapular vein (SSV) were estimated. Measurements and Main Results: The success of CT-V was achieved in 52 of 52 patients (100%). The mean angulation between the right EJV and the right SCV was 144 ± 36 degrees in the obtuse-angle cases (88%) and 72 ± 28 degrees in the sharp-angle cases (12%). A plexus of veins under the clavicle was most commonly responsible for insertion of the central venous catheter (CVC). The EJV approach resulted in a 93% rate of successful cannulations. No complications of pneumothorax or carotid artery puncture occurred during insertion procedures. Conclusions: The EJV route is associated with comparable technical success and lower major procedural complication. The EJV approach with CT-V guidance is an option as the initial method when central venous cannulation must be performed under suboptimal conditions.     

Pulmonary artery catheterization by the percutaneous approach to the axillary vein

The choice of venous access can be difficult in patients under intensive care. The axillary vein appeared interesting to evaluate. This prospective study involved 63 punctures carried out in 59 patients during a 16 month period (14 females and 45 males; mean age: 54 +/- 4 yr). 34 patients were tracheostomized and under controlled respiration; some had coagulation abnormalities (8 cases). The other 29 patients were undergoing a preoperative haemodynamic study. Puncture of the axillary vein was carried out with the needle inserted at an angle of 30 degrees to the skin surface and directed parallel to the artery medial to its course. The Seldinger technique was used (catheter and guide wire). Overall success rate was 87.5%. In 73%, less than three attempts were required. After the catheter was set in place in the axillary vein, the mean time required to reach the pulmonary artery was 7 +/- 15 min (range: 20 s-45 min). Less than 1 min was needed in 60%. Extrasystoles were observed in 3.6%. The incidence of arterial puncture was 11% without any late complications. In every case, pulmonary artery and capillary wedge pressure curves were obtained, as well as cardiac output measurements. Mean duration of catheterization was 2 +/- 1.1 days in the preoperative haemodynamic group and 4 +/- 1.7 days in the other. No infectious complication was related to the catheterization. One thrombosis of the axillary and subclavian veins was noted (1.8%). The axillary vein appeared therefore to be useful for pulmonary artery catheterization. It is an alternative choice in patients under controlled ventilation and with coagulation problems.     

Ultrasonography of the femoral vessels in the groin: implications for vascular access

The femoral artery and vein are commonly used for access to the circulation. Accidental puncture of one vessel whilst attempting to cannulate the other is a common complication. Identification of relevant surface anatomical landmarks and ultrasonography of both groins was performed on 50 consecutive adult patients admitted to the intensive care unit. In most patients there was overlap of the artery over the vein far closer to the inguinal ligament than conventional anatomical texts would indicate. The frequency and degree of overlap increased as the vessels descended distally towards the knee. Surface anatomical landmarks were not useful in predicting the underlying anatomy. The side-by-side relationship of artery and vein is commonest close to the inguinal ligament. Therefore, to avoid damage to the neighbouring vessel, percutaneous access should be undertaken just below the inguinal ligament.     

Vertical infraclavicular brachial plexus blockade

Brachial plexus blockade is routinously performed by using the axillary route. From clinical experience and anatomical point of view it is known that the axillary approach is not the ideal technique to achieve efficient brachial plexus anesthesia. Regarding the anatomical conditions, it is clear that the mid-retrosubclavian region should be the most appropriate place to apply the local anesthetic agent due to the fact that all three fascicles of the plexus are lying close together. During the past several decades different supra- and infraclavicular approaches have been described but none of them are still in use to a great extent today. Since 1993 we routinely have used the vertical infraclavicular approach, a self developed technique based on detailed anatomic studies. This method of brachial plexus blockade has clearly defined guidelines using simple reproducible landmarks and is performed by applying a strongly vertical puncture at the center line between the ventral apophysis of acromion (lateral landmark) and the jugular notch (medial landmark) directly beneath the clavicula. The patient is lying in a supine position with his forearm relaxed on the chest and his head slightly turned to the contralateral side. The brachial plexus is met in 3 to 4 cm depth. Because of its advantages the vertical infraclavicular blockade has become the most applied technique in upper extremity regional anesthesia in our hospital. The method has a high success rate, low risks, and a high acceptance by both patients and anesthetists. © 2003 Elsevier Inc. All rights reserved.