European Journal of Cardiovascular Medicine

For haemodynamic monitoring, vasopressor infusion, fast fluid resuscitation, and blood transfusions, central venous cannulation is frequently carried out in intensive care units and during major surgical procedures. Despite the methodological difficulties, the landmark approach has been used for many years. Nowadays, ultrasound guidance is regarded as the gold standard method for inserting a CVC.

From the lower border of the teres major to the outer border of the first rib, the axillary vein—which is the continuation of the basilic vein—continues as the subclavian vein.^[1]

Similar to the subclavian vein, the anterior rib cage forms the posterior boundary of the axillary vein in its more medial sections. However, the rib cage "falls away" inferiorly at the middle section of the vein, creating a larger space between the vein and the rib cage. Furthermore, a needle is more likely to slide off the rib cage rather than puncture it due to its steeper angle of fall. The rib cage is no longer behind the axillary vein as it moves laterally. Actually, there aren't any really weak spots behind the vein here.^[1]

In order to prevent difficulties, ultrasound is more dependable than the landmark approach and provides greater visualisation of the axillary vein. There would be a deeper vein in the lateral approach. The mean depth in the most lateral ultrasound picture was 3.2 (range 1.4±5.4) cm, 3.1 (1.3±5.1) cm, and 3.1 (1.1±5.6) cm in the midclavicular, 2-cm, and 4-cm slices, respectively.^[1,2,3]

The lateral imaging showed less of the rib cage. It would be less frequent near the vessels even if it is seen on the lateral view. As a result, the axillary vein is superior to the subclavian vein. Less commonly, the arm's posture will impact the vessels' visibility. Abduction of the arm won’t influence the much of vessel's diameter and depth.^[1,2,3]
The cross-section of the vessel may be seen with the use of out-of-plane imaging. This is achieved by putting the transducer axis perpendicular to the axis of the vessel.

The longitudinal plane of the vessel can be seen with the use of in-plane imaging. It is acquired by aligning the transducer's axis with the vessel's longitudinal axis. This view does not depict anatomical relationships and simply aids in visualising a single structure at a time. Therefore, before puncturing the vessel, prior confirmation is required.^[4]

After institutional ethical committee approval (ECR/486/Inst/KA/2013/RR-16)

CTRI/2023/05/052402 [Registered on: 09/05/2023] - trial registered prospectively.

The Department of Anaesthesiology at Karnataka Medical College and Research Institute, Hubballi, conducted a prospective study to evaluate ultrasound-guided in-plane versus out-of-plane transspectral right axillary vein cannulation in patients in need of a central line. The study was carried out in compliance with Good Clinical Practice standards and the Declaration of Helsinki, 2013. A computer-generated random number table was used for randomisation, and a single-blinded prospective research was carried out. Following informed, valid written agreement, 58 ASA physical status I and II patients over the age of 18 who were undergoing major surgery and in the critical care unit and who met al.l inclusion criteria were included to the research.

Study Period: August 2022 to July 2023(over the period of one year)

Study Design: Prospective randomized, single blinded, interventional study.

In order to be included, patients had to be in the American Society of Anaesthesiologists (ASA) physical status I or II, be between the ages of 18 and 60, be of either gender, give written, valid consent, and undergo any surgery that required CVC in an operating room or an intensive care unit.

After a thorough evaluation and an explanation of the procedure's benefits and drawbacks, patients who met the aforementioned requirements provided their informed written permission. A computer-generated randomisation method was used to randomly assign the 58 patients who were part of the trial into two equal groups.

The right axillary vein was reached in group 1 (n=29) using an out-of-plane ultrasound imaging approach.

In group-2 (n=29), the right axillary vein was accessed using in-plane ultrasound imaging.
There was a secured 18G IV line. Regular monitoring such as SpO2, NIBP, and ECG are linked. Vital parameter baseline measurements were recorded. Using the Seldinger method and a triple lumen 7Fr central venous catheter, the right axillary vein was centrally catheterised following the administration of general anaesthesia in operating rooms and ongoing baseline monitoring in the intensive care unit.

The method involved standing on the patient's right side with the ipsilateral arm adducted and the head tilted 30 degrees away from the vein puncture location. After being cleaned with povidone iodine solution, the right infraclavicular fossa, including the suprasternal notch, was covered.

The ultrasound machine was positioned at the left side of the patient to allow the operator to view both the ultrasound image and patient’s landmark. Ultrasound machine (LOGIQ V2, GE MEDICAL SYSTEM) equipped with high resolution of 3-11MHz, linear transducer was used. The transducer was covered with ultrasonic gel and wrapped in a sterile sheath.

Prior to the procedure The axillary vein's depth, calibre, and patency were assessed by ultrasonography. The axillary vein continues medially till it meets the subclavian vein at the first rib. To evaluate the axillary vessel's depth, diameter, and patency, a linear transducer was used to move laterally from the clavicular midline in out-of-plane imaging. The axillary vein was confirmed with a colour doppler.

Right axillary vein cannulation was performed on group -1patients using ultrasonic out-of-plane imaging, with a linear transducer held perpendicular to the vessel's long axis. The puncture site was selected laterally in the deltoid-pectoral sulcus, away from the costoclavicular structure, and in a section of adequate dimension.

Slowly advancing a needle allowed for the superficial detection of its trajectory or tip. Using an out-of-plane approach, the needle was moved in real time towards the vein lumen. The passage into the vessel was verified by the venous blood returning to the syringe. Following venous access, the needle was stabilised, the syringe was taken out, and the J-tipped guidewire was inserted smoothly and effortlessly all the way past the needle's end. The wire remained in place when the needle was taken out. Before entering the vessel, the dilator was pushed through the wire and into the skin. Before inserting the catheter into the skin, it was advanced across the guidewire while the wire was still under control. After removing the guidewire, all ports were examined for blood return. The catheter was fastened in position and all ports were flushed.

Right axillary vein cannulation was performed on group-2 patients  using ultrasonic in-plane imaging, with a linear transducer maintained parallel to the vessel's long axis. Using an in-plane approach on the longitudinal axis, the needle was moved gently and in real time towards the vein lumen. The passage into the vessel was verified by the venous blood returning to the syringe. After obtaining venous access, the catheter was inserted similarly to an out-of-plane method. The location of the catheter in the vein was verified using image intensification.

Following the surgery, a chest x-ray was taken to verify the catheter's location and rule out any problems in each patient.

The Statistical Package for Social Sciences (SPSS) version 22.0 was used to examine the data after it was imported into Microsoft Office Excel

The research covered 58 patients in total. The two groups' first attempt cannulation and demographic data distributions were similar.

In group 1 (out-of-plane technique), the mean weight was 61.59 ± 9.06 kg, while in group 2 (in-plane technique), it was 58.21 ± 6.52 kg. With a p-value of 0.1085, there was no statistically significant difference between the research groups. The groups' BMIs did not significantly differ from one another.

24 patients (82.76%) in group 1 (out-of-plane method) and 15 patients (51.72%) in group 2 (in-plane approach) underwent catheterisation on their first try. Five patients (17.24%) in group 1 (out-of-plane method) and fourteen patients (48.28%) in group 2 (in-plane approach) had more than one attempt at catheterisation. With a p-value of 0.0118, there was statistical significance between the groups.

In group 1 (out-of-plane technique), the mean needle redirections were 1.38 ± 0.78 times, while in group 2 (in-plane technique), they were 1.97 ± 0.94 times. A p-value of 0.0134 indicated that there was statistical significance between the groups.

The mean attempts were 1.24 ± 0.58 in group-1(out-of-plane technique) and 1.66 ± 0.81 in group-2 (in-plane technique) respectively. There was statistical significance between the groups with p-value of 0.0483.

Group 1 (out-of-plane technique) and Group 2 (in-plane technique) had mean access times of 6.10 ± 2.48 minutes and 10.72 ± 3.49 minutes, respectively. A p-value of 0.0001 indicated statistical significance between the research groups. One patient (3.45%) in group 2 had an arterial puncture using the in-plane approach. Group 1 (out-of-plane approach) experienced no difficulties during catheterisation. A p-value of 1.000 indicated no statistical significance.

Table 1: Comparison of two techniques i.e. in-plane and Out-of-plane with mean age and BMI by independent t test

*p<0.05

Table 2: Comparison of two techniques i.e. in-plane and Out-of-plane with status of first attempt cannulations

*p<0.05

Figure 1: Consolidated standards of reporting trials (CONSORT) diagram

Figure 2: Comparison of two techniques i.e. in-plane and Out-of-plane with number of needle redirections

Figure 3: Comparison of two techniques i.e. in-plane and Out-of-plane with number of attempts

In order to increase patient safety and precision, ultrasound guidance has become standard procedure for central line installation. ^[1] Despite advancements in catheter-related sepsis detection and insertion technique, central venous cannulation is linked to iatrogenic harm. Despite their inherent drawbacks, the internal jugular vein and the subclavian vein are often selected locations for central venous access. ^[5] The internal jugular vein location has a good first pass success rate in short axis view, but the long axis view is linked to the danger of carotid punctures, and IJV has a relatively higher infection incidence. However, the site is amenable to ultrasound guidance due to its unobstructed vision.^[1]

 Because of its permanent anatomical characteristics and ligaments that maintain its openness and accessibility during shock, the subclavian vein is an intrathoracic, non-compressible conduit. However, in patients on anticoagulants, there is an inherent risk of pneumothorax and haemothorax. Furthermore, an ultrasonography method is inappropriate due to clavicular acoustic shadowing.^[6]

The axillary vein was proposed by NavParkash S. Sandhu, MD^[7] as a viable choice for central venous access. Theoretically, problems such tracheal damage, mediastinal haematoma, haemothorax, and pneumothorax can be prevented by cannulating the axillary vein. A method of catheterising the axillary vein through the armpit was disclosed by Spracklen et al.^[8] in 1967. Their method, which relies on landmarks and palpation, was unsuccessful in 6% of instances. Twenty percent of their patients suffered pain and paraesthesia as a result of damage to the arm's medial cutaneous or ulnar nerves. Because the axillary is so close, there is a chance of neural damage.

Galloway and Bodenham ^[2] used ultrasonography to scan the axillary vein in 93% of their 50 patients and reported that the infraclavicular approach to axillary vein cannulation is safe and successful, sharing the benefits of the subclavian route while avoiding its difficulties. The safe and efficient substitute for internal jugular vein cannulation is transspectral axillary vein cannulation guided by out-of-plane ultrasonography. The axillary vein cannulation is beneficial because it is easily receptive to ultrasound guiding throughout the process, reducing the risk of problems including pneumothorax and haemothorax, minimising infection rates, and increasing patient safety.^[1]

First attempt cannulation: First attempt cannulation of the vein was defined as venous cannulation on the first skin puncture with no redirections of the needle.

In our study, 15 patients (51.72%) underwent in-plane catheterisation, and 24 patients (82.76%) underwent out-of-plane catheterisation on their first try. With a P value of 0.0118, the out-of-plane imaging approach had a considerably greater first try success cannulation rate than in-plane imaging.

Comparing out-of-plane and in-plane imaging techniques for transspectoral left axillary vein cannulation, Maddali MM et al ^[1] found that the out-of-plane technique had a higher first pass success rate (34 patients, or 79.06%) than the in-plane technique (20 patients, or 46.51%). Therefore, the author came to the conclusion that the out-of-plane ultrasonic approach is superior to the in-plane technique for cannulating the axillary vein. Our study is contradicted by a study by Sarah K. Sommerkamp et al.^[9] that compared longitudinal and transverse approaches to ultrasound axillary vein cannulation. The study found that the in-plane imaging technique had a higher first pass success rate (68%), compared to the out-of-plane technique (37%), with a P value of 0.01.

A retrospective cohort research on ultrasound-guided approach to the axillary vein in oblique-axis view combined with in-plane puncture was carried out by Fabrizio Bresica et al.^[10] with 80 cancer patients. The study concentrated on first attempt cannulation and related problems. 77 out of 80 patients (96%) had their axillary veins cannulated on their first try in the present study, which shows that combining an oblique axis view with an in-plane puncture increases the first pass success rate and reduces complications.

Number of attempts: The number of times the operator took the needle out of the skin puncture site and put it back in indicates the number of tries. If more than four tries are made, the surgery may be abandoned.  In our study, using out-of-plane imaging resulted in much fewer tries if the vein was not cannulated on the first try. Compared to out-of-plane imaging, which has a first pass success rate of 17.24%, in-plane imaging has a lower rate of 48.28%, with 14 patients requiring several attempts. Thus, in-plane imaging showed the most efforts, which were deemed significant with a P value of 0.04.

Needle redirections: The number of times the needle was pulled out and redirected without leaving the skin puncture site was known as the number of needle redirections. A p-value of 0.01 indicates that needle redirections were more common in the in-plane technique than in the out-of-plane approach in our study, which is deemed significant.

Duration of procedure: It is the amount of time that passes between the initial skin puncture and the successful implantation of the central venous catheter. If the process took more than 20 minutes, it was abandoned. With a p value of 0.001, which was statistically significant, the time required to access the axillary vein in our investigation was 6.10+/-2.48 minutes using an out-of-plane approach and 10.72+/-3.49 minutes using an in-plane technique. The right axillary vein cannulation operation took much less time overall in the out-of-plane group. When cannulation was performed under local infiltration on conscious patients, the process took longer.

In a study comparing longitudinal and transverse approaches to ultrasound axillary vein insertion, Sommerkamp et al.^[9] demonstrated that the longitudinal (in-plane) approach to the axillary vein during ultrasound guided venous access is faster than the out-of-plane technique using a torso vascular phantom. However, the time required to cannulate the right axillary vein using the long axis (in-plane) approach was longer and was statistically significant with a P value of 0.003 in a study by Prajakta Shinde et al.^[12] comparing the ultrasound guided infra-clavicular axillary vein cannulation versus internal jugular vein cannulation.

 In Maddali MM et al.'s study^[1] comparing ultrasound-guided out-of-plane versus in-plane imaging techniques for transspectoral left axillary vein cannulation, the out-of-plane technique took significantly less time to complete the cannulation procedure (P value = 0.01).

Complications and abandonment of procedure: Haematoma development, pneumothorax, and arterial puncture occurrences were taken into account. The second anaesthesiologist thought about stopping the surgery if the patient's safety became a worry. If any of the following occurred: the procedure took longer than 20 minutes, the guidewire would not pass over the needle even though blood flowed freely back through it, the ultrasound visualisation was poor in the first place due to breast tissue, or the number of attempts exceeded four, the procedure was stopped.

One arterial puncture occurred during the in-plane ultrasound imaging approach of venous access in our investigation. Thus, the process was dropped. According to the postoperative chest X-ray, none of the patients in either group in our research experienced pneumothorax. In a study comparing ultrasound-guided out-of-plane and in-plane imaging techniques for transspectoral left axillary vein cannulation, Maddali MM et al.^[1] found that four patients in the in-plane group and one patient in the out-of-plane imaging group had arterial punctures, which resulted in the procedure being abandoned; this difference was not statistically significant.

In a study on the safety and effectiveness of ultrasound-guided internal jugular vein cannulation versus ultrasound-guided infra-clavicular axillary vein cannulation in adult cardiac surgical patients, Prajakta Shinde et al.^[12] experienced arterial puncture during IJV cannulation, which was subsequently managed by pressure, and subsequently secured IJV on a second attempt. However, there were no issues with the cannulation of the axillary vein.

In conclusion, compared to in-plane imaging, ultrasound-guided right axillary vein cannulation performed using an out-of-plane imaging approach had a higher first try success rate and fewer needle redirections. With the out-of-plane method, the axillary vein may be cannulated more quickly and successfully. Therefore, a superior substitute for the internal jugular and subclavian veins is the axillary vein cannulation.

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2. Galloway S, Bodenham A. Ultrasound imaging of the axillary vein—anatomical basis for central venous access. British Journal of Anaesthesia. 2003 May 1;90(5):589-95.
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10. Brescia F, Biasucci DG, Fabiani F, Favarato M, Costa F, Longo F, Martuscelli M, Vitiello M, Pittiruti M. A novel ultrasound-guided approach to the axillary vein: oblique-axis view combined with in-plane puncture. The journal of vascular access. 2019 Nov;20(6):763-8.
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