Peter Belott, MD From the Electrophysiology Department, Sharp Grossmont Hospital, La Mesa, California. The axillary vein has become a desirable structure for venous access for implantation of debrillator and pace- maker leads because the vein is large, easily accessed, and can accommodate multiple leads. Furthermore, axillary vein access is not associated with problems accompanying sub- clavian vein access, including pneumothorax and subcla- vian crush syndrome. 1,2 The axillary vein can be accessed by a variety of tech- niques, ranging from a blind percutaneous puncture to the use of sophisticated tools such as ultrasound. Its use for device implantation was rst suggested by Byrd. 3,4 Axillary venous approach usually involves a progression from sim- ple to more complex techniques. 5 The following discussion focuses on a technique that uses simple supercial land- marks and the rst rib. This technique for axillary venous access has proved to be safe, expeditious, and time-effec- tive. Supercial anatomy Fundamental to access of the axillary vein is a complete understanding of the local supercial and deep anatomy. The important supercial landmarks are the clavicle, cora- coid process, and deltopectoral groove (Figure 1). These structures are easily palpated. Occasionally the axillary ar- tery pulsation can be palpated in the superior aspect of the deltopectoral groove. If palpable, it helps dene the location and course of the axillary vein, which runs medial and anterior to the artery. The coracoid process is the most prominent supercial landmark; it is a bony prominence easily palpated on the anterior shoulder. The deltopectoral groove is the crease in the anterior shoulder. It is formed by the lateral aspect of the pectoralis major muscle and the medial border of the deltoid muscle. The cephalic vein is found in the deltopectoral groove as it runs inferior to superior, joining the axillary vein. It often joins the axillary vein at a right angle (Figure 2). This explains the occasional difculty encountered when passing a lead via the cephalic vein. The clavicle is an important structure, as the axillary vein is found in the infraclavicular space as it rolls over the rst rib. Deep anatomy The axillary vein is a large venous structure that is the continuation of the basilic vein. It starts at the lower border of the teres major tendon and latissimus dorsi. The axillary vein terminates immediately beneath the clavicle at the outer border of the rst rib, at which point it becomes the subclavian vein. The axillary vein is covered anteriorly by the pectoralis minor, pectoralis major muscles, and costo- coracoid membrane. It is anterior and medial to the axillary artery and brachial plexus that it partially overlaps. At the level of the coracoid process, the axillary vein is covered only by the clavicular head of the pectoralis major muscle. It is at this point that the axillary vein receives the more supercial and lateral cephalic vein (Figure 3). Address reprint requests and correspondence: Dr. Peter H. Belott, 1625 E. Main Street, Suite 202, El Cajon, California 92021. E-mail address: pbelmd@msn.com. Figure 1 Relationship of the axillary vein to the pectoralis major and minor muscles, deltoid muscle, clavicle, and cephalic vein. 1547-5271/$ -see front matter 2006 Heart Rhythm Society. All rights reserved. doi:10.1016/j.hrthm.2005.10.031 Palpation After the patient is prepped and draped, the rst step is to palpate the supercial landmarks of the coracoid process, deltopectoral groove, and clavicle. With knowledge of the supercial and deep anatomy, these three structures help dene the usual location of the axillary vein. Palpating the structures also helps in planning the surgical incision. Oc- casionally the axillary artery can be palpated in the superior aspect of the deltopectoral groove and infraclavicular space. If the artery is palpable, it denes the location of the axillary vein, which runs anterior and medial to the artery. This enables orientation of the percutaneous needle to avoid an arterial puncture and facilitates successful entry into the axillary vein. Procedure Although the axillary vein can be accessed blindly through the skin, it is recommended that a skin incision be per- formed rst. This enables more precise location of the axillary vein by visualizing the deep anatomy of the del- topectoral groove and pectoralis major muscle. The skin incision is located at the level of, or just slightly below, the coracoid process and runs perpendicular to the deltopectoral groove (Figure 4). The incision is made just medial to the coracoid process in the middle of the deltopectoral groove and carried inferomedially in a direction perpendicular to the deltopectoral groove for approximately 2 inches. The incision is carefully carried down to the surface of the pectoralis major muscle. The pectoralis major muscle, del- topectoral groove, and deltoid muscle are visualized. The inframedial incision is preferred as opposed to an incision parallel to the deltopectoral groove because it allows for optimal visualization of the deep anatomy and allows for a more anteromedial pocket. Superiorly, the dissection is car- ried to the surface of the pectoralis major muscle and the Figure 2 A: Cephalic vein draining directly into the axillary vein just superior to the pectoralis minor muscle. B: Contrast venography of the axillary and cephalic vein. Figure 3 Detailed anatomy of the anterolateral chest demonstrating the relationship of the axillary vein to the pectoralis major and minor muscles and surrounding structures. 367 Belott Axillary Venous Access clavicle. In essence, the superior edge of the incision is dened by the pectoralis majorclavicular junction. The surface of the pectoralis major muscle is clearly visualized superiorly under the edge of the incision. The incision is held open with a Weitlaner retractor, which is continuously repositioned for optimal exposure. The purpose of this dis- section is to allow appropriate positioning of the percuta- neous needle over the axillary vein as it is advanced through the pectoralis major muscle. Although the axillary vein can be accessed blindly through the incision with a needle puncture 1 or 2 cm medial and parallel to the deltopectoral groove at the level of the coracoid process, use of the rst rib for orientation is recommended to avoid the rare but real incidence of pneu- mothorax. To access the axillary vein using the rst rib, the image intensier is pulled over to the incision and the rst rib is identied. It usually is the most superior U-shaped rib (Fig- ure 5). The ribs seen traversing medial to lateral in an inferior direction are posterior. Identifying the rst rib u- oroscopically is critical because if the operator misinterprets a posterior rib as the rst rib, a percutaneous stick will result in a pneumothorax or access to undesired cardiopulmonary structures. The rst step in accessing the axillary vein using the rst rib is to place the 18-gauge percutaneous needle and syringe on top of the pectoralis major muscle in the superior aspect of the incision. Using uoroscopy, the needle tip is placed in the middle of the rst rib (Figure 6). The angle of the syringe and needle is gradually increased as the needle is advanced through the pectoralis major muscle. The for- ward motion of the percutaneous needle and syringe should be such that the tip of the needle is maintained uoroscop- ically over the body of the rst rib. To maintain rst rib Figure 4 Orientation of the incision line with respect to the coracoid process and deltopectoral groove. Note the incision line is perpendicular to the deltopectoral groove. Figure 5 Radiograph demonstrating the location of the rst rib. Arrowheads point to the anterior border of the rst rib. Figure 6 Radiograph of the needle over the rst rib. The needle tip is maintained in this position as the needle and syringe are advanced. This is accomplished by increasing the steepness of the needle angle. 368 Heart Rhythm, Vol 3, No 3, March 2006 orientation, a rather steep angle generally is required. Nee- dle advancement is continued until the rst rib is struck. In essence, this maneuver attempts to pin the axillary vein to the rst rib (Figure 7 ). Once the rst rib is touched, the needle and syringe are slowly withdrawn under suction until the vein is entered, as indicated by a ash of blood in the syringe. If the rst pass is unsuccessful, the needle and syringe are moved either medially or laterally and the ma- neuver repeated until the vein is entered. Once the vein is entered, the guidewire is passed and the sheath applied per standard technique. If the needle is advanced toward the rst rib through tissue or muscle without the needle tip visual- ized uoroscopically directly over the rst rib, the shallow angle may result in the needle passing between intercostal spaces, leading to a pneumothorax. It is recommended that a gure-of-eight stitch be applied above the needle punc- ture for hemostasis and the retained guidewire technique used for multiple lead placement. 6 Occasionally, the axillary vein cannot be found or ac- cessed by this technique. In this case, alternate approaches are recommended. The rst is the use of radiographic con- trast. 7,8 Rarely, the axillary vein is found to be completely occluded or nonexistent, with collateralization from other veins over the clavicle. If contrast can identify the axillary vein, it is simply accessed by placing the needle tip in the middle of the contrast. Once again, it is recommended that the rst or second rib be used for needle tip orientation to avoid pneumothorax by inadvertently passing the needle through an intercostal space. An alternate approach, if avail- able, is the use of ultrasound to visualize the axillary vein and artery. An ultrasound probe is placed through the inci- sion on top of the pectoralis major muscle and used to identify the artery and vein. The vein usually is medial and nonpulsatile, and it collapses with inspiration. The needle is passed parallel to the probe through the pectoralis major muscle into the vein guided by direct visualization on the ultrasound screen. It is extremely important to understand the supercial and deep structural and uoroscopic anatomy. The rst rib is a key uoroscopic landmark. Occasionally, axillary ve- nous access by the approach described is unsuccessful; in this case, traditional cutdown techniques of the cephalic vein or percutaneous access of the subclavian vein are recommended. References 1. Fyke FE III. Infraclavicular lead failure: tarnish on a golden route. Pacing Clin Electrophysiol 1993;16:373376. 2. Magney JE, Flynn DM, Parsons JA, Staplin DH, Chin-Purcell MV, Milstein S, Hunter DW. Anatomical mechanisms explaining damage to pacemaker leads, debrillator leads, and failure of central venous cath- eters adjacent to the sternoclavicular joint. Pacing Clin Electrophysiol 1993;16:445447. 3. Byrd CL. Safe introducer technique for pacemaker lead implantation. Pacing Clin Electrophysiol 1992;15:262267. 4. Byrd CL. Clinical experience with the extrathoracic introducer insertion technique. Pacing Clin Electrophysiol 1983;16:17811784. 5. Magney JE, Staplin DH, Flynn DM, Hunter DW. A new approach to percutaneous subclavian needle puncture to avoid lead fracture or cen- tral venous catheter occlusion. Pacing Clin Electrophysiol 1993;16: 21332142. 6. Belott PH. A variation on the introducer technique for unlimited access to the subclavian vein. Pacing Clin Electrophysiol 1981;4:4348. 7. Spencer WK III, Zhu DWX, Kirkpatrick C, Killip D, Durand JB. Subclavian venogram as a guide to lead implantation. Pacing Clin Electrophysiol 1998;21:499502. 8. Ramza BM, Rosenthal L, Hui R, Nsah E, Savader S, Lawrence JH, Tomaselli G, Berger R, Brinker J, Calkins H. Safety and effectiveness of placement of pacemaker and debrillator leads in the axillary vein guided by contrast venography. Am J Cardiol 1997;80:892896. Figure 7 Needle trajectory in relationship to the rst rib. The superior needle is piercing the axillary vein. The needle tip is touching the rst rib. The lower needle with a shallow angle runs the risk of entering an intercostal space, causing pneumothorax. 369 Belott Axillary Venous Access