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Table of Contents
Year : 2017  |  Volume : 33  |  Issue : 3  |  Page : 289-290

Axillary vein cannulation for central access: A newer look below the clavicle!

Department of General Anesthesiology, Center for Critical Care and Department of Outcomes Research, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH 44195, USA

Date of Web Publication11-Sep-2017

Correspondence Address:
Ashish K Khanna
Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, G.58, Cleveland, Ohio 44195
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_354_16

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How to cite this article:
Khanna AK. Axillary vein cannulation for central access: A newer look below the clavicle!. J Anaesthesiol Clin Pharmacol 2017;33:289-90

How to cite this URL:
Khanna AK. Axillary vein cannulation for central access: A newer look below the clavicle!. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2021 Mar 5];33:289-90. Available from:

The journey from supervision to being a supervisor is not easy.[1] As an early attending, I can vouch for this. This is especially obvious when teaching trainee procedures such as central venous access. The other problem is new skill acquisition at the level of an attending. Scarcity of patients, competing with trainees, and not wanting to experiment on a real patient are some very valid concerns herein. In this issue of the Journal of Anaesthesiology Clinical Pharmacology, Adhikary et al. report a pilot manikin study on ultrasound-guided axillary vein (AXV) cannulation. The authors evaluated the efficacy of a training model for teaching this method of vein cannulation. They also compared the acceptability of this technique looking at attending anesthesiologists versus residents in training.[2]

The use of the AXV for central access has been described for quite some years now.[3],[4] With the advent of superior sonographic technology, the modern ultrasound probe has been able to truly look “below the clavicle” and allow for real-time image-guided axillary or distal subclavian access. The advantages favor safety as in any other ultrasound-guided central access technique. However, the degree of difficulty is certainly much more than using the ultrasound for cannulating the internal jugular vein (IJV). Specifically, the AXV is a smaller vessel and is located underneath a layer of muscle. In addition, even after visualization, the approach angle for the finder needle is very steep. This is very different from the traditional teaching for the landmarks guided subclavian access where the essence is to stay parallel to the chest wall and underneath the clavicle. Importantly, this also means that any postpointing or loss of needle trajectory may lead to a puncture of the pleura or the subclavian artery, both being disastrous consequences in themselves.

Adhikary et al. examine the use of a manikin model for simulated learning of this skill set.[2] The advantages of the use of simulation for teaching have been seen in high-stress situations in the operating room.[5] In addition, procedural skills in critical care medicine including but not limited to central venous access are supported by favorable evidence.[6] In this study, the manikin acts as a simulator and allows for learning in a scenario where mistakes will not be as costly as on a real patient.

The authors used an innovative approach to manikin-based simulation training. In a prospective, unblinded, observational model, they allowed participants to insert central lines in an alternating, sequential manner on the IJV and the AXV. They recorded time from probe placement to guidewire in the central vein as time to line placement. In addition, they also compared needle punctures, defined for the purposes of the study as needle withdrawal (not necessarily out of the manikin). The results tell a tale in themselves. IJV cannulation time started improving from the very first attempt whereas the same was not seen until the third attempt with the AXV. Understandable, since most operators start with a degree of confidence with the ultrasound-guided IJV cannulation at baseline. Overall, cannulation time for IJV was significantly shorter than that for AXV cannulations (P = 0.046). This seems like a reasonable (to be expected) result. However, the data for AXV cannulation are impressive, with an overall reduction for ultrasound-guided in-plane cannulation time by 46% (median 34 s). For an in-plane ultrasound-guided approach to the AXV, this improvement is remarkable. Also interestingly, when attending anesthesiologists and residents were compared for the speed of skill acquisition, the results brought forth subtle differences. The authors reported that attending anesthesiologists started with a lower cannulation time at baseline but showed minimal improvement in those times for IJV cannulation. Compared to this, residents started with higher cannulation times but improved to a significantly lower time. This difference may be explained by possibly a good inherent skill at IJV cannulation at the attending level, but the lack of improvement also suggests a slower skill acquisition time or a lack of motivation to acquire this new skill set at a previously well-mastered technique. These differences were not that remarkable in the manikin-guided AXV cannulation where a consistent improvement as expected was seen in anesthesiologists' and residents. Perceptions toward a preferred site for venous cannulation remained in favor of the IJV.

This study opens up a number of questions. While it is understandable that residents had a shorter learning time overall and that AXV cannulation showed a clear learning pattern, it remains very surprising that the residents preferred an anatomical and not an ultrasound-guided IJV approach before this study. The authors attribute this to the lack of access to US machines and also comment on the underutilized transverse technique at central cannulation. I strongly question both observations. Firstly, the use of US technology for central venous access is an integral part of training for most academic anesthesia programs in the United States. Second, most central venous access is routinely performed using a transverse rather than an in-line approach.

All said and done, this study opens up a tremendous avenue for further scientific investigation. This is truly an important pilot investigation. However, the results need cautious interpretation. They may be regarded as a signal in a direction and no more. Again, the signal to noise ratio is remarkably noisy here. I would encourage the authors to reconstruct a similar trial with far fewer outcomes and a simpler design. Perhaps, the need of the hour is to move away from traditional ultrasound-guided IJV cannulation and emphasize on the image-guided in-line AXV cannulation. Perhaps, the time has come for a newer look below the clavicle!

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Conflicts of interest

There are no conflicts of interest.

  References Top

Frankel HL, Syed M, Khanna A. Fellow as a Resident Teacher – The Journey from Supervision to Supervisor. Available from:  Back to cited text no. 1
Adhikary S, McQuillan P, Fortunato M, Owen D, Liu WM, Thiruvenkatarajan V. A manikin-based evaluation of a teaching modality for ultrasound-guided infraclavicular longitudinal in-plane axillary vein cannulation in comparison with ultrasound-guided internal jugular vein cannulation: A pilot study. J Anaesthesiol Clin Pharmacol 2017;33:337-41.  Back to cited text no. 2
  [Full text]  
Khatibi B, Sandhu NP. Real-time ultrasound guided axillary vein cannulation. J Perioper Echocardiogr 2015;3:42-7.  Back to cited text no. 3
Galloway S, Bodenham A. Ultrasound imaging of the axillary vein – Anatomical basis for central venous access. Br J Anaesth 2003;90:589-95.  Back to cited text no. 4
Rajan S, Khanna A, Argalious M, Kimatian SJ, Mascha EJ, Makarova N, et al. Comparison of 2 resident learning tools-interactive screen-based simulated case scenarios versus problem-based learning discussions: A prospective quasi-crossover cohort study. J Clin Anesth 2016;28:4-11.  Back to cited text no. 5
McSparron JI, Michaud GC, Gordan PL, Channick CL, Wahidi MM, Yarmus LB, et al. Simulation for skills-based education in pulmonary and critical care medicine. Ann Am Thorac Soc 2015;12:579-86.  Back to cited text no. 6

This article has been cited by
1 European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access)
Massimo Lamperti,Daniele Guerino Biasucci,Nicola Disma,Mauro Pittiruti,Christian Breschan,Davide Vailati,Matteo Subert,Vilma Traškaite,Andrius Macas,Jean-Pierre Estebe,Regis Fuzier,Emmanuel Boselli,Philip Hopkins
European Journal of Anaesthesiology. 2020; 37(5): 344
[Pubmed] | [DOI]


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