Anesth Analg 2004;99:562-565
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000130396.31225.E4
CRITICAL CARE AND TRAUMA
The Use of Ultrasound for Axillary Artery Catheterization Through Pectoral Muscles: A New Anterior Approach
NavParkash S. Sandhu, MD
Department of Anesthesiology, New York University School of Medicine, New York, New York
Address correspondence and reprints to NavParkash S. Sandhu, MD, Department of Anesthesiology, NYU School of Medicine, 550 First Ave., New York, NY 10016. Address e-mail to navparkashsandhu @hotmail.com.
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Abstract
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A palpable axillary artery pulse is a prerequisite for introducing an arterial line. The close proximity of four nerves to the artery increases the chance of nerve injury, especially in anesthetized patients. The highly colonized entry site results in frequent infection. Approaching the axillary artery through the pectoral muscles by using real-time imaging should improve success, decrease infection, and prevent nerve and vessel injuries because these structures and the needle can be visualized directly. I describe three patients who had successful axillary lines placed through the pectoral muscles by using real-time sonography. The ability to see the artery, surrounding nerves, and vein and to observe the needle going through the tissues should increase safety and success, although a large study is needed to prove these hypotheses.
IMPLICATIONS: Axillary artery catheterization through the armpit is associated with nerve injuries and frequent infection. Our technique of introducing the catheter through the pectoral muscles by using real-time sonography allows imaging of the artery, the surrounding nerves, and the needle. This may increase both success and safety by decreasing nerve injuries and infection.
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Introduction
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The axillary artery is cannulated for monitoring of arterial blood pressure and arterial blood sampling when other arteries, such as the brachial, radial, dorsalis pedis, and femoral arteries, either are impalpable because of vasospasm, peripheral vascular disease, or thrombosis or are unavailable because of inclusion of these arteries in the operative field. An axillary arterial line is traditionally placed by palpating its pulsations in the axilla and then puncturing it with the Seldinger technique (1). The axillary artery pulse is not always easily palpable because of obesity, muscular hypertrophy, or arterial disease. The axilla is also difficult to dress, and catheterization interferes with arm mobility and patient comfort. Furthermore, perspiration in the axilla may cause bacterial proliferation and is frequently associated with sepsis when lines are maintained longer than 3 days (2). Hayashi et al. (3) have described an ultrasound-guided subclavian approach for implanting long-term ports into the aorta or its branches for cancer chemotherapy. An anterior approach to the axillary artery with real-time sonography is described.
In this technique, the arm is abducted to 90° to straighten the course of the axillary artery. A 4- to 7-MHz C-11 sonographic probe (Sonosite, Bothell, WA) is used to obtain a longitudinal view of the axillary artery (Figs. 1 and 2). Its location should be confirmed by its vigorous pulsation, incompressibility, and cephalad position relative to the axillary vein. An 18-gauge needle is advanced under real-time imaging through the pectoral muscles and clavipectoral fascia (the cords of the brachial plexus should be carefully avoided while the needle is advanced), and the axillary artery is punctured with a short, jabbing motion at its most anterior point. The puncture may take several attempts, because the artery tends to slip to the side. After aspiration of a few milliliters of blood, the needle is advanced a few more millimeters under real-time imaging (Fig. 2). The artery is then catheterized by using Seldinger’s technique. A dilator is advanced with a slow to-and-fro rotating motion to dilate the tract, and the free movement of the guidewire is confirmed after every few millimeters of advancement to ensure that a false tract is not being created, in which case the guidewire will not move freely. The dilator advance should be monitored under real-time imaging until the dilator’s tip reaches the arterial wall. To prevent excessive bleeding and hematoma, the arterial puncture should not be dilated. In awake patients, lidocaine 1% is injected into skin and muscle; the procedure is well tolerated by patients.
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Figure 1. Relationship of the ultrasound probe to the axillary artery, needle, and brachial plexus. The axillary artery in its distal part is surrounded by branches of the brachial plexus on all four sides, increasing the likelihood of nerve injury. AA = axillary artery; AV = axillary vein; M = medial cord; L = lateral cord; C = clavicle; P = ultrasound transducer.
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Case Reports
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Case 1
A 30-yr-old man who fell from a five-story building was brought emergently to the operating room (OR) with an open and severely comminuted fracture of the right thigh, a fractured ankle, open fractures of both bones of the right arm, and a head injury. He also had a fractured pelvis and blunt trauma to the abdomen. He was tracheally intubated in the emergency room and brought to the OR. He was severely hypotensive because of major persistent bleeding, with a systolic blood pressure between 50 and 70 mm Hg. Several attempts to insert a left radial arterial line failed. His axillary artery was punctured with a needle, and a guidewire was advanced by using the technique described by Adler and Bryan-Brown (1). The guidewire went no more than 3 or 4 cm before meeting resistance, and attempts to redirect the guidewire resulted in a periarterial hematoma. The needle and the wire were removed, and the artery was compressed. The femoral artery could not be cannulated because the general surgeons had already started an exploratory laparotomy. His left anterior chest was prepared with povidone-iodine, and, with the Seldinger technique, a 16-gauge catheter was passed into the axillary artery under real-time sonography.
Case 2
A 22-yr-old man was brought to the OR for decompression of a pericardial effusion. He had previously had an insertion of a chest tube in the left thorax and a right thoracotomy for repair of diaphragm and liver lacerations after blunt trauma, followed by a complicated postoperative course. Both radial arteries were thrombosed as a result of repeated arterial line placements during his previous surgeries. Coagulation was normal. An axillary arterial line was placed by using ultrasonography before the induction of general anesthesia.
Case 3
A 41-yr-old woman with Larsen syndrome (characteristic facies, joint instability, cervical spine instability, laryngomalacia, and cardiac septal defects) (4), a right midfemur fracture, left femoral neck and fibular fractures, and a right arm fracture after a motor vehicle accident came to the OR for emergency hip surgery and cast placement on the right arm. Her short neck, anteriorly placed larynx, and possible cervical injury prompted us to perform an awake fiberoptic intubation with topical lidocaine for airway anesthesia. On induction, the patient had a cardiac arrest. She was successfully resuscitated after three direct-current shocks. The femoral arteries (because of bilateral femur fractures) and right radial artery were not available for arterial line placement. Her left radial and brachial arteries were impalpable. An axillary artery line was placed through the pectoral major and minor muscles, and the needle was advanced under real-time imaging into the axillary artery. An 8.5F introducer sheath was also placed into the axillary vein by using Seldinger’s technique under real-time sonography (Figs. 3 and 4). Her coagulation profile was normal.
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Figure 3. Axillary artery (16G) and axillary venous line (8.5F sheath) in a patient with Larsen syndrome.
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Figure 4. Chest radiograph of Case 3, showing the axillary arterial line (white arrows) and axillary venous line (black arrows).
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Discussion
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Catheterization of the axillary artery is highly dependent on palpation of its pulse (1,5,6). Edema, hematoma, obesity, spasm, muscular hypertrophy, or a decreased diameter due to peripheral vascular disease may render the axillary pulse impalpable. Imaging of this artery with ultrasound may eliminate these obstacles. In a study of 435 patients, Bryan-Brown et al. (6) found that trainee residents required more than 2 attempts in 70% of patients and failed in 30%. Attending staff failed to puncture the artery in 5% of primary attempts and 7% overall. Two of their patients developed distal ischemic complications, and one had an injured ulnar nerve. De Angelis (5) reported 90% success in a series of 86 cases.
Real-time imaging of artery, needle, and nerves should theoretically eliminate nerve injuries and improve success (7). This technique carries no risk of pneumothorax because the needle is advanced under imaging, the artery lies outside the thoracic cage, and the needle is advanced at such an angle that it may encounter the subscapularis muscle or scapula but not the chest wall. A small hematoma may result from unsuccessful cannulation. This may be easily controlled in a thin patient by pressure over the puncture with the transducer or in heavier individuals by compressing the artery against the first rib with a thumb or transducer. The expanding hematoma can be easily observed as a hypoechoic area, and with a color Doppler device, a jet of blood can be easily identified by sonography and corrective measures instituted. When the axillary artery catheter is removed, the subclavian artery should be firmly compressed with the thumb over first rib for 5 minutes to prevent hematoma formation.
The large size of the axillary artery implies that the incidence of thrombosis will be less than in the radial or dorsalis pedis artery. If thrombosis occurs proximal to the origin of arterial branches around the scapula, serious ischemia may result, requiring immediate thrombectomy. If thrombosis is distal to these branches, scapular collaterals will maintain good perfusion despite complete occlusion of the axillary artery.
In a prospective study, Norwood et al. (2) observed that 44% of axillary arterial catheters and 56% of entry sites were colonized. This frequent contamination seems understandable, because the axilla is always wet except in severe dehydration, which results in a large bacterial content of the axillary skin. Most line sepsis arises from the entry site and progresses into the vessels (8). Approaching the artery through the anterior chest wall should minimize this problem. This needs to be proven by a large prospective study.
The hollow of the axilla also makes the entry site difficult to dress, and dressings tend to detach from the wet skin. The presence of a catheter in the axilla is uncomfortable for the patient and interferes with arm mobility. In contrast, a dressing on the anterior chest wall is associated with none of these problems. Infection of subclavian venous lines is very infrequent, and a similar rate may be expected in a transpectoral axillary artery line.
When the guidewire is advanced blindly, it may enter one of the branches of the axillary artery, leading to failure. If the advance of the guidewire is observed by real-time sonography, it can be renegotiated back into the main arterial lumen when necessary.
The axillary artery is surrounded superiorly by the lateral cord, posteriorly by the posterior cord, and inferiorly by the medial cord of the brachial plexus. There is a large proximal segment with no nerves on its anterior surface, which makes it safer than the axillary approach, where the nerves surround the artery. In the proximal segment of the axillary artery, the nerves appear as hyperechoic structures in a transverse view of the neurovascular bundle. In a longitudinal view, only one of the cords can be seen (Fig. 2).
The tip of an axillary arterial line is very close to the aortic arch on the left and to the carotid artery on the right. Extreme caution should be used while flushing the line, because a small amount of air can easily enter the cerebral circulation. It is very important to flush the line slowly with a syringe rather than by opening the valve of the high-pressure bag to prevent excessively high pressure. The stopcock should be very close to the entry site to decrease the amount of fluid that is required for the flush.
Hirota et al. (9) observed brain infarction in 5.6% of their cancer patients who had arterial ports for chemotherapy inserted through the left subclavian artery or one of its branches. The reason for these high thromboembolic strokes may have been long-standing ports (8–307 days) and excessive looping in the aortic arch. We used our catheters for much shorter periods until achievement of hemodynamic stability, discontinuation of vasoactive drugs, or successful cannulation of another peripheral artery.
There was no difference between the left and right sides in terms of performing the arterial puncture, but the possibility of the guidewire or the catheter entering the right carotid artery should be diminished by sonographic imaging after line placement. A comparison of different arterial catheterization sites is shown in Table 1.
All the lines described in this report were placed by the author; thus, it is difficult to predict the learning curve for this technique, but the simplicity of recognizing the pulsatile artery and nerves should make it a simple technique for almost anyone to learn.
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Acknowledgments
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I thank Dr. Sanford Miller and Dr. Shyamala Karuvannur for their help in editing this manuscript.
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References
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- Adler DC, Bryan-Brown CW. Use of the axillary artery for intravascular monitoring. Crit Care Med 1973; 3: 148–50.
- Norwood SH, Cormier B, McMahon NG, et al. Prospective study of catheter-related infection during prolonged arterial catheterization. Crit Care Med 1988; 16: 836–9.[Web of Science][Medline]
- Hayashi N, Sakai T, Kitagawa M, et al. Percutaneous long-term arterial access with implantable ports: direct subclavian approach with ultrasound. Eur J Radiol 1998; 26: 304–8.[Medline]
- Tobias JD. Anesthetic implications of Larsen syndrome. J Clin Anesth 1996; 8: 255–7.[Web of Science][Medline]
- De Angelis J. Axillary arterial monitoring. Crit Care Med 1976; 4: 205–6.[Web of Science][Medline]
- Bryan-Brown CW, Kwun BK, Lumb PD, et al. The axillary artery catheter. Heart Lung 1983; 12: 492–7.[Web of Science][Medline]
- Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002; 89: 254–9.[Abstract/Free Full Text]
- Schlichtig RI. Arterial catheterization: complications. In: Tobin MJ, ed. Principles and practice of intensive care monitoring. New York: McGraw-Hill, 1998: 751–6.
- Hirota T, Yamagami T, Tanaka O, et al. Brain infarction after percutaneous implantation of port-catheter system via the left subclavian artery. Br J Radiol 2002; 75: 799–804.[Abstract/Free Full Text]
Accepted for publication February 19, 2004.
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Abstract
Introduction
