Dynamic variation of the axillary veins due to intrathoracic pressure changes: A prospective sonographic study

Abstract

Introduction: The ultrasound-guided axillary vein is becoming a compulsory alternative vessel for central venous catheterization and the anatomical position offers several potential advantages over blind, subclavian vein techniques. Objective: To determine the degree of dynamic variation of the axillary vein size measured by ultrasound prior to the induction of general anesthesia and after starting controlled mechanical ventilation. Design: Prospective, observational study. Methods: One hundred ten patients undergoing elective surgery were enrolled and classified according to sex, age, and body mass index. Two-dimensional cross-sectional vein diameter, area, and mean flow velocity were performed using ultrasound on both the left and right axillary veins of each subject before and after induction of anesthesia. Results: There was statistically significant evidence showing that the axillary vein area increases when patients are mechanically ventilated. When considering venous flow velocity as a primary outcome, velocity decreased after patients moved from spontaneous to mechanical ventilation (coefficient = −0.267), but this relationship failed to achieve statistical significance ( t = –1.355, p = 0.179). Conclusions: Anatomical variations in depth and diameter as well as the collapsibility due to intrathoracic pressures changes represent common challenges that face clinicians during central venous catheterization of the axillary vein. A noteworthy increase in vessel size as patients transition from spontaneous to mechanical ventilation may theoretically improve first-pass cannulation success with practitioners skilled in both ultrasound and procedure. As a result, placing a centrally inserted central catheter after the induction of anesthesia may be beneficial.

Effects of ipsilateral tilt position on the cross-sectional area of the subclavian vein and the clinical performance of subclavian vein catheterization: a prospective randomized trial

“…Therefore, the primary venipuncture success rate may be clinically related to the increased first-pass success rate of subclavian vein catheterization and may decrease catheterization-related complications. A recent study also suggested that an increase in the axillary vein area during mechanical ventilation may theoretically improve the first-pass success rate of central venous catheterization [12]. Accordingly, this study examined whether the primary venipuncture success rate could be improved by increasing the csSCV.…”

“…For last decades, the use of ultrasonography during vascular procedures has been suggested as a standard method that enhances overall success and reduces procedure-related complications, by professional organizations [ 9 – 11 ]. Ultrasonographic assessment can be applied before, during, and after central venous cannulation, and provides clinicians with advantages of success, speed, and safety, by visualizing vessel viability, size, and patency, as well as the location of other adjacent anatomically important structures [ 12 , 33 ]. With respect to ultrasound-guided subclavian vein catheterization, although the quality of evidence is generally weak, the use of ultrasound-guidance is recommended in adult patients [ 9 ].…”

“…Although ultrasonography is widely used during vascular access in most medical facilities, and is recommended as a standard method during central venous catheterization by a number of professional organizations [ 9 – 11 ], a traditional landmark-based technique is still important and useful in certain clinical situation where the ultrasonography is not promptly available or when the operator is not familiar with the equipment. For anatomical landmark-based technique, although it is still uncertain how much increase in the cross-sectional area of the vein will affect the success of catheter placement, the cross-sectional area of the vein can theoretically have an impact on the success rate of venous catheterization by affecting the venipuncture success rate [ 12 ]. Previously, the cross-sectional area of the subclavian vein (csSCV) was shown to be affected by head, shoulder, or arm positioning [ 13 – 18 ], as well as by changes in intrathoracic pressure during mechanical ventilation [ 12 ].…”

“…For anatomical landmark-based technique, although it is still uncertain how much increase in the cross-sectional area of the vein will affect the success of catheter placement, the cross-sectional area of the vein can theoretically have an impact on the success rate of venous catheterization by affecting the venipuncture success rate [ 12 ]. Previously, the cross-sectional area of the subclavian vein (csSCV) was shown to be affected by head, shoulder, or arm positioning [ 13 – 18 ], as well as by changes in intrathoracic pressure during mechanical ventilation [ 12 ]. However, the effects of the ipsilateral tilt position of the patient on the csSCV have yet to be investigated.…”

The role of PEEP for cannulation of the subclavian vein: A prospective observational study

“…The role of positive endexpiratory pressure (PEEP) for successful cannulation of the subclavian vein (SCV) remains inconclusive [ 1 , 2 ]. A higher PEEP may decrease distance from SCV to the parietal pleura consecutively increasing the periprocedural risk of pneumothorax.…”