Ultrasound guided infraclavicular axillary vein cannulation, coming of age.

In this month’s journal Ahn and colleagues report the effect of arm abduction on the success of central catheter placement after ultrasound guided infraclavicular axillary vein (AXV) cannulation. We discuss these findings and reflect on the development of this particular route of access to central veins. This paper presents good evidence that arm abduction increases the success of central catheter placement with this approach from the right side and therefore reduces one problem of this procedure. This has parallels with peripherally inserted central catheters (PICC) placement where it is routine to put arms out on a board, albeit primarily to aid vein access on the medial aspect of the upper arm. The malposition rate when the AXV was punctured in the neutral position and was significantly higher than with the arm abducted. It is suggested that arm abduction opened up the curve between the subclavian vein and superior vena cava (SVC) to aid central passage of the guidewire. Interestingly there were four arterial punctures in the neutral group but none in the abducted group, which might also suggest abduction favourably altered either the size of the vein, or its degree of overlap with the artery. This was not measured by the authors. There are other measures to reduce or correct misplacement of central venous catheters. These include: