Arm position and collapsibility of infraclavicular axillary vein during voluntary breathing: An ultrasound-guided observational study

Abstract

Background: Arm abduction influences cross-sectional area of the infraclavicular axillary vein, yet the effect of arm abduction on collapsibility of the vein has not been quantified. Decrease in collapsibility of the axillary vein can enable successful cannulation and can decrease injury to underlying vital structures. Methods: The infraclavicular axillary vein was scanned in 70 patients close to the clavicle with a high-frequency linear transducer in arm adducted position (Point A), after arm abduction at the initial probe position (Point A′) and after tracing the vein medially close to clavicle (Point B). Maximum and minimum cross-sectional area and circumference during tidal breathing and collapsibility indices during tidal and deep breathing were measured at three probe positions. Results: The percentage change with respiration in cross-sectional area, circumference and the collapsibility indices computed from the above measurements were lesser in arm abducted position (p < 0.001). There was decrease in collapsibility index during tidal breathing from 25 at Point A to 7 at Point A′ and 3 at Point B. Collapsibility index reduced from 91 at Point A to 30 at Point A′ and 35 at Point B during deep breathing. Conclusion: We conclude that the collapsibility of the infraclavicular axillary vein could be reduced by arm abduction, and hence, abduction could be proposed as the ideal arm position for ultrasound-guided infraclavicular axillary vein cannulation.

Influence of arm position on the first pass success rates of ultrasound-guided infraclavicular axillary vein cannulation in spontaneously breathing patients: A randomised clinical trial

“…Arm abduction moves the lateral end of the clavicle cephalad over the rib cage, 15 and this exposes the 2-3 cm proximal length of IAV, otherwise obscured by the post acoustic shadow of the clavicle when the arm is in a neutral position. 8,15 This proximal portion of the IAV is also less collapsible because it is tethered to the clavipectoral fascia enclosing the subclavius muscle. 16 As the IAV ascends over the rib cage it receives the cephalic venous drainage and at its proximal end, becomes more prominent and superficial before disappearing under the clavicle.…”

“…3,4 Attempts to cannulate the vein with marked collapsibility can increase the number of needle punctures and result in serious complications such as pneumothorax and arterial puncture in a non-compressible region. The Trendelenburg position, 5 retracted shoulder position 6 and arm abduction [7][8][9] have been evaluated for their ability to improve venous diameter and decrease collapsibility. Among these, arm abduction was shown to significantly decrease the collapsibility index and increase the cross-sectional area and circumference of the vein during spontaneous breathing.…”

“…Among these, arm abduction was shown to significantly decrease the collapsibility index and increase the cross-sectional area and circumference of the vein during spontaneous breathing. 8 This observation can have important implications in reducing the number of needle passes and attempts required for IAV cannulation; however, evidence to support this hypothesis is lacking. Hence, we have designed this study to analyse the influence of two different arm positions (arm in neutral or abducted to 90° at the shoulder joint) on the first pass success rate of guidewire placement during IAV cannulation in spontaneously breathing patients.…”

Feasibility of Ultrasound-Guided Axillary Vein Puncture under Valsalva Maneuver for Diagnostic and Cardiovascular Interventional Purposes: Pacemaker and Cardioverter-Defibrillator Implantation

“…Thanks to the direct visualization of the targeted vein without the use of nephrotoxic iodinated contrast media, USGAVA minimizes exposure to ionizing radiation during fluoroscopy [29,30]. Despite USGAVA proving to be a reliable method for CIED implantation, the respiratory variation in AV size during tidal breathing, which can lead to complete venous collapse [31,32], represents a significant challenge for successful vein puncture and cannulation. Asking the patient to hold a forced expiration for a few seconds, as prescribed by the Valsalva maneuver, has the potential to address these challenges.…”

Comments on: Ultrasound-guided subclavian cannulation using open door technique – A technical report

“…[ 3 ] Conversely, arm abduction by 90° elevates the lateral end of the clavicle by 3.5 cm, exposing approximately 3 cm of the proximal IAV. [ 4 ] This medial segment of the IAV is larger and less collapsible, facilitating high first-pass success compared to the neutral arm position. Hence, we propose arm abduction as the optimal position for ultrasound-guided IAV cannulation.…”