INTRODUÇAO: A obtençao do acesso venoso para implante de dispositivos cardíacos
eletrônicos implantáveis (DCEIs) tem sido tradicionalmente feita por meio da
punçao da veia subclávia intratorácica (PVS) ou por flebotomia da veia
cefálica (FVC). Evidências apontam, entretanto, para o risco aumentado de
complicaçoes a curto e longo prazos com a PVS pelo fato de ser um acesso
intratorácico e pelo risco de compressao dos eletrodos pelo ligamento
costoclavicular, levando a diferentes tipos de defeitos. A FVC, por sua vez,
tem sido associada à taxa de insucesso que chega a 45%. A punçao da veia
axilar (PVA) tem sido descrita na literatura e é apresentada, aqui, como
alternativa às duas técnicas mencionadas.
MÉTODOS: Realizou-se uma pesquisa pelo PubMed sobre artigos que mencionam as técnicas de PVA, PVS e FVC e que as comparam quanto aos resultados imediatos, a curto e longo prazos e taxas de sucesso para a obtençao do acesso venoso. Deu-se ênfase às comparaçoes entre as diversas técnicas de PVA.
CONCLUSAO: A técnica de PVA para obtençao do acesso venoso apresenta algumas variaçoes entre os diversos autores. Ela tem segurança semelhante à da FVC, taxas de sucesso comparáveis às da veia subclávia e melhores resultados a médio e a longo prazos para a funçao dos eletrodos.
Palavras-chave: Punçao da veia axilar; Flebotomia da veia cefálica; Punçao da veia subclávia; Complicaçoes com implante de marcapassos.
|Citation: Pegoraro VR, Costa ERB, Gouvea Filho LFF, Paiva BTC. Puncture of the Axillary Vein for the Implant for Electronic Cardiac Devices. Arq Bras Cardiol 32(1):17. doi:10.24207/jac.v32i1.511_PT|
|Received: Fevereiro 18 2018; Accepted: Julho 09 2018|
Obtaining venous access for implantation of implantable cardiac devices (ICDs) is an essential part of the procedure. The choice of puncture technique should take into account factors such as the chance of success, the risks of immediate and future complications and the time required to obtain them. Several techniques have been described, all with their particularities and limitations. The intrathoracic subclavian vein puncture (SVP) technique was introduced by Littleford et al.1, in 1979. It was widely accepted because it is fast, easy to learn, and has high success rates. Thus, it has been the most widely used electrode implant method in the world2-4. In Brazil, this is also the most used venous access, followed by cephalic vein phlebotomy (CVP). Subclavian access, however, is associated with a greater risk of both immediate complications - pneumothorax, hemothorax, arterial puncture, brachial plexus injury and late - insulation defects, electrode fractures, capture losses, abnormal impedances and sensing failures5,6. CVP, although quite safe, has been less and less used due to the failure rate that varies from 15 to 45%7.In this work, we will review the axillary vein puncture technique (AVP), presenting the similarities and variations between the different authors, as well as their respective success rates, and compare it with the other techniques.
A PubMed survey was conducted on articles that mention AVP techniques. Those who described the AVP techniques or those who compared them to those of SVP or CVP were selected for immediate, short- and long-term results, and success rates for obtaining venous accesses.The survey covers articles published between 1979 and 2017. Emphasis was placed on comparisons between the various AVP techniques.
The axillary vein originates from the junction of the cephalic and basilic veins. It extends to the lower margin of the first rib where it continues as the subclavian vein ending with its junction with the internal jugular8.
AVP can be performed using contrast venography, contrast-free fluoroscopy, ultrasonography, or even anatomical landmarks only.
For fluoroscopy-guided AVP, data from venography studies that evaluate the usual path of the axillary vein are used. One demonstrated that the axillary vein runs parallel to the deltopectoral sulcus (DPS) between one finger (1.85 cm) and one finger and a half (2.8 cm) more medially and follows its course towards the most prominent point of the clavicle (MPPC)9.
This MPPC approximately corresponds to the crossing of the clavicle with the lateral margin of the first rib10,11. The axillary vein in its course parallel to the DPS also passes over the anterior body of the second rib, at the point where it crosses over the posterior shadow of the third rib (lateral radiological limit of the rib cage). Thus, with fluoroscopy, the needle can be directed to one of these two points from the pacemaker pocket (Fig. 1).
To reach these points, several authors have used varied techniques that can be generally grouped into two methods. In the first one, it begins by making the incision to the IECD pocket below (1.5-2 cm) and parallels to the clavicle, with this extending to the DPS. Then, the puncture needle is coupled to a syringe and puncture is performed from the IECD pocket. The tip of the needle is placed from the IECD pocket under fluoroscopy on the first rib, with an initial angle of approximately 60º (steep angle) in relation to the body surface (BS). The needle is then advanced and if it passes from the rib margin it is partially withdrawn and reintroduced with a greater angle (which can reach 90º) so that it is always seen on the first rib while it is advanced. From the moment it touches the rib, aspiration begins at the same time the needle is slowly drawn back. If blood cannot be aspirated, the process is repeated a little more laterally or medially, always with the needle on the radiological image of the first rib. The same technique can be used with the needle directed to a second target: the second rib body at the point where it intersects with the posterior shade of the third rib - which leads to more lateral puncture of the vein. Care should be taken that the needle always points to the anterior arch of the target rib since the inadvertent choice of a posterior arch may cause the needle to cross the intercostal muscles and the puncture result in a pneumothorax12,13.
In the second method, the incision can be made on the DPS or slightly medial to it (in the second case, it is approximately on the usual path of the axillary vein). The needle is inserted under fluoroscopy from the pacemaker's pocket at a lower angle (shallow angle) to the skin (10-30°), targeting the same crossing point of the clavicle with the lateral face of the first rib.This puncture angle allows greater needle reaches to puncture the axillary vein from the DPS (Fig. 2). This method of puncture was first described by Byrd10and subsequently used by others14.
Magney15 was the first to use anatomical landmarks for AVP, which was done transcutaneously. Gardini and Benedini16, using the same anatomical references, began to perform the puncture from the inside of the IECD pocket, both described in Table 1. The techniques that came after the axillary vein were targeted in their passage through the crossing of the lateral margin of the first rib with the clavicle (CC1C) or more lateral portions of this, in the latter case, on the crossing of the anterior aspect of the second rib with the posterior shadow of the third. For this purpose, the DPS (or cephalic vein) can be used as the anatomical landmarks as the point of origin and the MPPC as the target point.The latter, being palpable, serves as a target to guide the direction of the needle. With the knowledge that the axillary vein passes 1.8-2.8 cm medially to the DPS, the needle - aligned with the vein path - is directed to the place where the MPPC is palpated9,17. In this case, the puncture should be made on the superficial pectoral muscles with a small angle (up to 30º) in relation to BS. If success were not achieved, it would be possible to use fluoroscopy with contrast venography from cannulation of the cephalic vein (if it was dissected to be used as a reference) or from a peripheral vein to identify any anomalous path17.
|References||Incision for the IECD pocket||XR||Puncture site/target /angle||Sucess rate|
|Magney et al.15||Not described||No||Entry (percutaneous puncture): junction of the 1/3 middle and 1/3 lateral of a line between PC and MEA midpoint.Target: 1/3 medial junction with 1/3 medial clavicle.||Not described|
|Ramza et al.25||Parallel to the clavicle (2 cm below)||Yes XR+C||Target: 1) Axillary vein in more medial or "in" portion of the rib cage; 2) Axillary vein in more lateral or "out" portion of the rib cage.*Angle: 60º with SC. Parallel to the vein.||Medial: 100% Lateral: 83%┼|
|Gardini et al.16||Parallel to the clavicle (2 cm below)||No||Modified Magney's technique, same references, but with the puncture from the inside of the pocket and not percutaneous.||98%|
|Belott12||Starts slightly below the coracoid process and runs perpendicular to the DPS||Yes||Target: 1) First rib at the intersection with the clavicle; 2) Second rib on the lateral margin of the rib cage (where the anterior radiological remnant of the second rib crosses the posterior radiological shadow of the third rib).Angle: 60-90º (steep).||98,21%|
|Sharma et al.20||On the DPS||Yes||Entry: crossing point of the second rib, with radiological lateral margin of the rib cage.Angle: 60ºTarget: Crossing of the clavicle with the lateral edge of the first rib.||98,09%|
|Antonelli et al.11||Parallel to DPS(1 cm medial to it) and 2 cm below the collarbone||Yes||Entry: upper incision edge.Target: 1st rib crossing with the clavicle.Angle: tangential to the thoracic surface.||94,5%|
|Jiang et al.14||Parallel to clavicle||No╬||Entry and angles: Steep needle technique - the angle of 60º in relation to BS.From point 2 cm medial to DPS.Shallow needle technique: From the lateral portion (closest to SCP) of the incision with a 10º angle to the BS.Target: 1/3 to 1/4 plus a medial portion of the clavicle.||Blind/XRSteep: 51/54%Shallow: 89/94%|
|Mehrotra et al.9||Parallel to the DPS, 1 finger and a half medial to it. Top of the incision lies 2 fingers below the collarbone||No||Entry: with the needle in the direction of the incision (one finger and medial half to the DPS). Target: MPPCAngle: 60º in relation to BS||95%|
|Migliori et al.13||Parallel to the clavicle (2 cm below), extending up to 1 cm medial to DPS||Yes||Target: 1) Crossing the clavicle with the lateral edge of the first rib; 2) Body surface of the second rib (at the point where the anterior shadow of the second rib crosses the posterior shadow of the third)Angle: 60º.||93,2%|
|Imnadze et al.17||Parallel to the clavicle (2-3 cm below) going to the DPS, where the cephalic vein was dissected||Entry: 1.5-2 cm medial to the cephalic vein, leaving the needle parallel to it. Target: axillary vein in the most distal portion. Angle: 30º in relation to BS, with a needle parallel to the cephalic vein.||92,6%|
|Squara et al.19||Parallel to clavicle||Yes||Same Bellot technique.||81%|
Target: vein point to be punctured [when more than one possible target point can be used (one or the other), have been set to 1 or 2]; MSA: manubrium-sternal angle; IECD: implantable electronic cardiac device; entry: entry point of the punch needle to then be directed to the target; PC: coracoid process; MPPC: most prominent point of the clavicle; RX: radioscopy/fluoroscopy; RX + C: contrast radioscopy; BS: body surface; DPS: deltopectoral sulcus; shallow: angle punch of approximately 10º-30º; steep: angle punch between 60º and 90º.
* Ramza used contrast venography and divided the axillary vein into medial and lateral. The medial portion corresponded to the vein "inside" the rib cage bone; the lateral portion to the axillary vein outside the limits of the rib cage.
┼ in all patients from Ramza who did not succeed with a more lateral puncture, success was obtained when the most medial puncture was subsequently use d.
╬ Jiang et al. initially tested for AP blindly, followed by fluoroscopy if it did not work
Pittiruti et al.18, in axillary vein Doppler studies, have shown that abduction of the arm, especially if associated with a certain shoulder elevation (with compresses behind the shoulder, for example), increased the diameter of the axillary vein and may facilitate its blind puncture18.
Obtaining venous access by the intrathoracic subclavian can be justified by the premise that the best way to do a procedure is to do the way one has the most experience. In fact, this has been the most used technique in Brazil and worldwide2-4. Several data, however, have shown that other forms of venous access with punctures that access the vascular bed in an extrathoracic location, such as AVP, may be equal or easier, safer, and present a lower risk of short- and long-term complications19-24.
Because the subclavian vein is a vessel with intrathoracic stroke, its puncture has been more associated with acute complications, especially the occurrence of pneumothorax (1.9-3.06%) when compared to AVP14,20,25 (Table 2). An example was a population cohort of 28,860 patients (Danish cohort) with IECD implantation evaluated for the occurrence of pneumothorax requiring drainage. The greatest predictor of its occurrence was obtaining access by SVP [odds ratio (OR) = 7.8; 95% confidence interval (95% CI) 4.9-12.5]26. The most frequent complication associated with AVP was the occurrence of an arterial puncture in the attempt to obtain venous access. CVP is practically not associated with acute complications, except for the possible occurrence of hematoma at the pocket location.
|References||Patients (n)||Pneumothorax (%)||Hemothorax (%)||Arterial puncture (%)||Pocket bruise (%)||Brachial plexus injury (%)||Limb thrombosis (%)||Success (%)|
ND: not described, unspecified or without separation of values between groups compared;
* Jiang shallow and steep are part of the same work but represent different axillary vein access techniques.
┼ authors who defined as the occurrence of pneumothorax only the cases requiring drainage. Cases without drainage are not included;
╬ cases of pneumothorax requiring drainage in which the implanted pacemaker was a double chamber.
The techniques described for AVP aim to use reference points that facilitate puncture without the risk of complications. If it is possible to perform it without the use of contrast, complications can be avoided such as spasm of the vein, nephropathy in patients with already depressed renal function, anaphylaxis or the need for adequate venipuncture ipsilateral to the puncture site. High success rates have been described for AVP using as reference fluoroscopic or only anatomical landmarks8,11,13,16,19,20, reserving the use of contrast for failure cases. When compared to the SVP technique, AVP has demonstrated similar success rates for vein cannulation19,20. AVP was even associated with a higher success rate in the first puncture attempt than SVP (61 vs. 36.8%),20. Although having a lower success rate, CVP has always been associated with greater safety, both because it is an extrathoracic technique and because it does not cause inadvertent risk of arterial puncture or brachial plexus injury. To test the safety of AVP, Squara et al.19 evaluated the AVP without the venography, comparing it with the CVP in a center where no electrophysiologist received any training or had any experience with the AVP. They only received material with a detailed description of the Belott technique before attempting to use the technique for the first time. With similar safety results - among them no pneumothorax - and high success rate, it has been shown that the lack of experience should not be impeding the adoption of AVP as a technique of choice19. A Brazilian study also confirmed its safety and efficacy27.
The techniques for AVP aim to use anatomical or radiological references for points on which the axillary vein passes more frequently, to facilitate the obtaining of the venous access. For this purpose, the various authors described their techniques with variations in relation to the pocket location, needle entry site, the target site for axillary vein puncture and needle angle for puncture. The latter can be large (60-90º - steep) or small, to the point of torsening the rib cage (10-30º - shallow) (Table 1). In general, when the pockets were made parallel to the clavicle, larger angles were used between the needle and SC, because there was greater proximity to the crossing of the first rib and clavicle (CC1C). In contrast, pockets parallel to DPS were associated with smaller angles for puncture when the target was CC1C - larger when the axillary vein was positioned more lateral (near the lateral radiological margin of the rib cage).
Ultrasonography can be used to guide the AVP. It certainly offers advantages such as direct visualization of the vessel and its anatomical relationships28, but it has the disadvantage that it is necessary to have this equipment in the room and also to extend the procedure.
When the possible consequences of the different types of access to the vascular bed on the durability of the electrodes were evaluated, important differences were observed.
Kim et al.22 compared the SVP technique with that of AVP in the insertion of 1,161 pacemaker electrodes. There was a 53% reduction in the risk of complications electrode fracture or defects in insulation - with axillary access compared to subclavian. Chan et al.23 followed the occurrence of failures in 681 implanted electrodes for an average period of 73.6 (± 33.1) months and the occurrence of defects was identified as 2.9%. AVP was an independent predictor for lower risk of electrode failure compared to SVP [hazard ratio (HR) = 0.26; 95% CI 0.071-0.954). Jacobs et al.24 made an even more detailed evaluation of defective electrodes extracted with the use of electrical tests, light microscopy, electron microscopy, and tests to evaluate the pressure on the electrodes. The analysis of the electrodes by specialists showed that the occurrence of pressure in the costoclavicular transition was responsible for the greater incidence of defects when the venous access was subclavian and suggested a more lateral approach, such as the use of the axillary vein, as a preventive for these complications.
The AVP technique has been described by several authors and presents some variations. It is a valuable alternative for obtaining venous access, presenting similar safety to CVP (even in the learning phase), success rates comparable to those of the subclavian vein and better medium and long term results for the function of the electrodes.
To Dr. Eduardo R. B. Costa for guiding us in this work.