Axillary Art Lines in Adults?

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foshizzo

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Anybody doing these? Curious as to which catheters you are using. We have 4.0 Fr / 10cm micropuncture introducer sets, and 18g / 6inch Argon art line kits - not sure which is better to use.

Is the transpectoral approach better than the armpit approach? Also, do you worry about kinking when the arms are tucked (ex/ cardiac cases)? Thanks for any insight!
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I have done them but only in emergencies. I used the regular 20g arrow catheter.
 
Noyac said:
I have done them but only in emergencies. I used the regular 20g arrow catheter.
Click to expand...

I prefer a longer catheter. The regular 20 g arrow isn't that long and with the soft tissue and movement from moving arms it can become dislodged.
 
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psychbender said:
I've only done a few, but used the catheters from the femoral art line kits or pediatric IJ kits that we have.
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Ditto. Arrow kits are too impractical for Ax lines, especially for the avg American (read Obese) patient.

I have never tried transpectoral, I always do armpit approach. Also, kinking is rarely an issue as these are large gauge vessels, unlike the radial.
 
foshizzo said:
Anybody doing these? Curious as to which catheters you are using. We have 4.0 Fr / 10cm micropuncture introducer sets, and 18g / 6inch Argon art line kits - not sure which is better to use.

Is the transpectoral approach better than the armpit approach? Also, do you worry about kinking when the arms are tucked (ex/ cardiac cases)? Thanks for any insight!
Click to expand...

Ax a-line is my goto site for difficult radials. Quick, easy under u/s or even palpation in thin pts, and reliable results.

I use arrow fem a-line kit. Used to suture them in, now just mastisol and tegaderm.
 
Pretty reliable. I know some who prefer them to brachials because they are safer theoretically, though I haven't seen a complication with a brachial a-line
 
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I have done them for trauma cases where radial wasnt good, but its hard to thread because the anatomy of the area isnt conducve to a single thread
 
You gentlemen care to leave some axillary line pearls? Brachial and then femoral have been my failed radial options but I am interested in trying the axillary spproach.
 
I use femoral a line kit. One needs to be careful in flushing axillary a lines because of risk of air bubble embolisam to carotids
 
Thanks for the replies - much appreciated!

Not much in the adult literature that I can find. Sandhu published a small case series of the anterior transpectoral approach in 2004. Vetrugno subsequently published a case of a psuedoaneurym and pectoral muscle hematoma with that approach for a mini-MVR. A colleague of mine had a horrific axillary hematoma and brachial plexus palsy with an armpit axillary arterial catheter while he was an ICU fellow in Florida.

My take-home: perhaps brachials are a better choice for anticoagulated patients / cardiac cases (easier to compress), and axillaries for vasculopaths who will not be anticoagulated (better collateral flow, less risk of thrombosis). References:

1) The use of ultrasound for axillary artery catheterization through pectoral muscles: a new anterior approach.
Sandhu NS. Anesth Analg. 2004 Aug;99(2):562-5.

2) Pectoral Muscle Hematoma After Axillary Artery Catheterization in a Patient Undergoing Minimally Invasive Mitral Valve Surgery
Luigi Vetrugno, MD, Rodolfo Muzzi, MD, and Francesco Giordano, MD
Journal of Cardiothoracic and Vascular Anesthesia, Vol 21, No 1 (February), 2007: pp 96-9
 
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I use the pediatric central line kit for axillary arterial lines. I've done about 25 in my career. I use u/s and go high up in the arm pit (very near the pectoralis muscle). This technique will avoid kinking of the catheter if the arms are tucked.

My success rate for axillary lines is 100 percent and I've never had one fail intraop unlike radial or brachial arterial lines. In fact, I've had more than a few radial arterial lines fail within an hour of placement if the stick was exceptionally difficult due to PVD.

Femoral arterial lines work well but they are dirty compared to an axillary line. In addition, morbidly obese patients require someone to hold up their huge fat gut while you place the line.
 
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You've had brachial art lines fail? I would've thought brachial would be robust (I've placed maybe one brachial ever, zero axillary). Granted, with ultrasound you can hit the radial anywhere from wrist to elbow, so I think brachial and axillary and DP are a thing of the past (if US available). Maybe femoral art lines for post circ arrest when radial craps out.
 
Oggg said:
You've had brachial art lines fail? I would've thought brachial would be robust (I've placed maybe one brachial ever, zero axillary). Granted, with ultrasound you can hit the radial anywhere from wrist to elbow, so I think brachial and axillary and DP are a thing of the past (if US available). Maybe femoral art lines for post circ arrest when radial craps out.
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If you haven't done an Axillary A-line under U/S then you haven't done enough A-lines. Next time you are struggling with a tough Radial A-line move the U/S up the arm and go high up into the armpit (Pectoralis almost). There you will find a large round pulsating structure just waiting to be accessed by you. I use a Pediatric Central line kit with excellent results; I go out of plane as well.
 
BLADEMDA said:
If you haven't done an Axillary A-line under U/S then you haven't done enough A-lines.
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I do not find an axillary a-line to be any cleaner than a femoral in the vast majority of the patients I see.
 
I haven't done an USG ax art line because I've haven't had to go brachial or higher ever since I started doing USG radials, watching the tip fully enter the artery
 
Oggg said:
I haven't done an USG ax art line because I've haven't had to go brachial or higher ever since I started doing USG radials, watching the tip fully enter the artery
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With severe PVD (the type I see daily) Radial and even Brachial arterial lines can fail shortly after placement. I have asked the Vascular surgeon to place a groin line from time to time if the patient is having a lower extremity revascularization.

For severe PVD Femoral lines can be more difficult than Axillary A lines. Just some food for thought. If what are you are doing is working then ignore this thread. But, if you encounter a patient where arterial access is difficult just keep in mind the Axillary approach usually works when all others fail.
 
I also do USG radials for all my hearts.

Sometimes, both radials are tortuous, calcified, plaque-filled little corkscrew pipes of angel-hair pasta. Bilaterally.

On these very rare occasions, I'll go brachial.

I just don't see the need for axillary, like, ever.

But to each their own.
 
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foshizzo said:
Anybody doing these? Curious as to which catheters you are using. We have 4.0 Fr / 10cm micropuncture introducer sets, and 18g / 6inch Argon art line kits - not sure which is better to use.

Is the transpectoral approach better than the armpit approach? Also, do you worry about kinking when the arms are tucked (ex/ cardiac cases)? Thanks for any insight!
Click to expand...

Never had to rescue a failed radial with an axillary art line during all of residency and a ICU fellowship. My go-to was mid-forearm U/S guided radial with a longer catheter (10cm 20g catheter from the Arrow femoral art line kit). The only people that THIS technique didn't work on was severe vasculopaths...just moved up to brachial in the AC or mid-upper-arm...
 
Outstanding discussion, It was a relief finding out that this is in fact a growing controversy.
My background is not Anesthesia, but I humbly practice in Critical Care.
Had this year 3 cases on wich we considered and ended up placing Transpectoral Anterior U/S guided Axillary Arterial Lines (As Described by Sandhu in Anesth Analg 2004), using real time Ultrasound In plane longitudinal approach.
However this small experience taught us, it is a very friendly arterial line. It is not uncommon to use the axillary artery for direct cannulation for CPB (using standard cannulas, short term approach evidently, specially for circulatory arrest-aorta cases) or indirect techniques using ussually side-grafts that have become popular even for long term VA ECMO access or Impella 5.0. Surgeons wield the consideration of 4 collateral systems and relatively uncommon atheroscleroticn involvement, . We used it in two evar-tevar patients who had to undergo aorto-monoilliac abdominal endografts with femoro-femoral grafts, so using the femoral approach was probably not wise; and the vascular surgeons had to use brachial access to cannulate the renal arteries. They worked very well and for a considerably long period of time. we used the 20g 10 cm arrow kits and personally I think the advantages are low displacement chance, the fact that the anterior approach places the line in the anterior chest wall and not in the armpit, easy fixation (can even be covered with the same adhesive/tegaderm for the subclavian line), and a reliable BP reading. Even found this review regarding complications (Critical Care 2002, 6:198-204) Wich I think is well favorable.
Nevertheless I would like to ask the forum what are your opinions on the chances of nervous injury, I think this is the main issue when placing this lines?
and how do you think this should be avoided?
Many thanks,
 
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The in plane longitudinal approach is virtually the same technique used to place subclavian/axillary central venous lines with Ultrasound
 
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Hawaiian Bruin said:
I also do USG radials for all my hearts.

Sometimes, both radials are tortuous, calcified, plaque-filled little corkscrew pipes of angel-hair pasta. Bilaterally.

On these very rare occasions, I'll go brachial.

I just don't see the need for axillary, like, ever.

But to each their own.
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Totally agree. I'm in a busy practice where we do a lot of alines. If I can't get a flash after a min or 2 I call for u/s. If I can't thread the wire after 2 attempts I move to the other side then go brachial. Ive seen guys struggle for 30 mins on an aline and not really change what their doing. Insane...
 
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ryanjmy said:
Totally agree. I'm in a busy practice where we do a lot of alines. If I can't get a flash after a min or 2 I call for u/s. If I can't thread the wire after 2 attempts I move to the other side then go brachial. Ive seen guys struggle for 30 mins on an aline and not really change what their doing. Insane...
Click to expand...

I just use it the first time every time. Not because I think it is safer but because in the population I am placing it in (old vasculopaths) and in my hands, it is more efficient. We also have several sonosites available at any given time.
 
Mman said:
I do not find an axillary a-line to be any cleaner than a femoral in the vast majority of the patients I see.
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I agree with you and this is a very important consideration, traditional axillary lines unavoidably would come in permanent contact with the armpit area carrying a significant risk of contamination- even though evidence shows only 0.51% incidence of attributable sepsis (5 of 1989 patients)-. But with the anterior transpectoral approach the location is practically the same as in a subclavian venous line, wich I think is comfortable for the patient and reasonable in terms of Contamination.
Since this is a very good and academically prolix discussion, I'd sure like to read some opinions of interested practitioners like you regarding this
Thank you all for your opinions and input, this is a very valid and valuable way to learn
image.jpg
 
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I use the 18ga catheter that comes over a needle as your guidewire introducer in the standard triple lumen kit, as it's longer and I like to have a syringe on draw back. I go a little more distal, kind of between axillary and brachial, to avoid the armpit and kinking. But with U/S you can really put it anywhere.
 
Why is an axillary Aline safer than a brachial?
Also when you are placing USG alines do you do them in complete sterile fashion with probe sheath? Doesn't this add a significant amount of time to the procedure over palpation?
 
Colba55o said:
Why is an axillary Aline safer than a brachial?
Also when you are placing USG alines do you do them in complete sterile fashion with probe sheath? Doesn't this add a significant amount of time to the procedure over palpation?
Click to expand...
For radial or brachial art lines we don't use a sterile field. Tegarderm over the probe to keep it clean, alcohol swab and get down to business.
 
If done properly, there is a 99% chance of successful access to the axillary artery on first attempt. In comparison to Femoral artery, I find it easier to manipulate the guidewire as it has a relatively straight path. Femoral artery goes beneath the inguinal ligament and in some patients, guidewire gets stuck in that path.

With our population getting obese, femoral artery access is relatively difficult (abdominal panus covers the groin). In obese patients femoral artery is also deeper. Even in most morbidly obese patients, axillary artery is still less than 2.5cm deep as medial side of arm doesn't gain as much subcutaneous fat.

Axillary Artery blood pressure (like Femoral Artery) is more accurate than radial artery, as these are more central vessels. Since the catheters are long, there is very little chance of it losing waveform or inaccuracy with prolonged use. I have not had had to remove a single one of these for malfunction so far. Infection risk is also minimal if strict sterile precautions are used.

There is a common misconception that Axillary Artery puncture or catheterization has risks of compromising arm circulation. This is not true. Axillary Artery has six major branches and collateral circulation is provided via Dorsal Scapular, Subscapular, Anterior and posterior humeral circumflex artery to the arm. As long as procedure is done proximally (close to axilla above the Teres minor muscle), it is very safe. Care should be taken in Brachial artery punctures (Axillary Artery become brachial artery below the Teres Minor muscle) as there can be a risk of arm ischemia.

I find Axillary Arterial punctures and catheterizations a very important tool for hemodynamic monitoring of critically ill patients in my ICU (Intensive Care Unit). With ultrasound use, it is very easy, safe and can be used effectively to provide better care to our patients.

http://www.bilalnaseer.com/journal/2012/3/10/axillary-arterial-lines.html
 
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Blade,

How does one know they are above the teres minor? After placement, do you make the arm stay at 90 deg? It seems the catheter and all the other crap after it is hooked up would really get in the way and annoy an awake patient.
 
Read&DifferentialDx said:
I agree with you and this is a very important consideration, traditional axillary lines unavoidably would come in permanent contact with the armpit area carrying a significant risk of contamination- even though evidence shows only 0.51% incidence of attributable sepsis (5 of 1989 patients)-. But with the anterior transpectoral approach the location is practically the same as in a subclavian venous line, wich I think is comfortable for the patient and reasonable in terms of Contamination.
Since this is a very good and academically prolix discussion, I'd sure like to read some opinions of interested practitioners like you regarding this
Thank you all for your opinions and input, this is a very valid and valuable way to learnView attachment 195575
Click to expand...


Please look at the picture. Those of you doing an Infraclavicular block can modify your technique to do Axillary Arterial lines. Move the probe slightly inferior and as lateral as possible. Go out of plane and hit the axillary artery. It's quite simple and easy to do.
 
epidural man said:
Blade,

How does one know they are above the teres minor? After placement, do you make the arm stay at 90 deg? It seems the catheter and all the other crap after it is hooked up would really get in the way and annoy an awake patient.
Click to expand...


If you are close to the arm pit (even the lower portion of the arm pit) you are above the teres minor.
 
Move the U/S probe as far lateral on the chest wall as possible; of course, the probe will be below the clavicle. I usually stick out of plane. The picture isn't close to the actual U/S position as it is much more lateral to avoid a pneumo. The arm is abducted like when you do an AX block

53eaa82d4781b435e4a04826bf155a31f0bcf6ae.jpg
 
This is very interesting. I routinely place 2-5 Aline's a day when at our more acute locations but have never thought to do axillary approach. Did a brief Internet search and did not find much in the way of useful instruction. Does anyone have a PDF or video tutorial? Mostly interested in pt position, landmarks, and us planes. Thanks.
 
Sandhu NS, ANESTH ANALG 2004;99:562–5

"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 guide-wire 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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