Right Versus Left Distal Axillary Approach For Subclavian Vein Cannulation

Alexandria University

Status: Completed

Conditions: Infraclavicular Vein Cannulation; Venous Cannulation

Treatments: Procedure: Ultrasound guided right infraclavicular approach of subclavian vein cannulation; Procedure: Ultrasound guided left infraclavicular approach of subclavian vein cannulation

Study type: Interventional

Funder types: Other

Identifiers

NCT06761326

Axillary subclavian approach

Details and patient eligibility

About

Central venous cannulation is an essential procedure in the anaesthetic and critical care practice. Ultrasound has revolutionized the practice favoring the internal jugular cannulation to the other sites .Subcalvian vein cannulation has fallen out of favor mainly due to the difficult visualization with the ultrasound, especially in obese patients and the inevitable position of the clavicle acting as a bony obstacle , in addition to the anatomical position in vicinity to the pleura which might raise the risk of pneumothorax . Indeed the subclavian vein cannulation is more comfortable and tolerated by the patient especially those requiring long term intravenous therapy, with less rates of infection and thrombosis. This mandated the development of a safer and efficient technique for the cannulation empowered by the ultrasound technology.

The infracalvicular approach or the proximal axillary vein cannulation has been described but is not popular. It provides a potentially safer and successful technique with less complication both in "experienced" and "less experienced"operators . All the patients will receive general anaesthesia with laryngeal mask insertion . Careful sterilization of the surgical site and strict aseptic techniques for the handling of the ultrasound probe will be pursued

Full description

All patients will be in supine position, with the arm abducted to 45 degrees , the angle of the arm will be adjusted to acquire best image. The probe will be placed in he parasagittal plane in the deltopectoral groove medial to the coracoid process . The image will be optimized regarding the depth , focus and the gain accordingly for the best image of the axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the axillary vein . The needle will be introduced in real time imaging , in an in-plane technique and blood will be aspirated , the guidewire will be introduced in real time imaging .The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin, Infraclavicular incision will be performed for the port site , the port will be secured in a dissected pocket right above the pectoralis major muscle .Flush back will be confirmed from the port .The incision will be closed in layers .The final position of the catheter tip will be confirmed using fluoroscopic guidance. In case of difficult visualization or failure of cannulation of one side , the subclavian vein of the contralateral side will be scanned and cannulated . The internal jugular vein will be the cannulated instead if any further difficulties were encountered .

Enrollment: 80 patients

Sex: All

Ages: 20 to 70 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

.Patients requiring porta Cath insertion.

Exclusion criteria

• Abnormalities in the platelet count or coagulation
• Thrombosis of the target vein
• Soft tissue infection of the overlying area
• Fracture of the clavicle or proximal ribs
• Patients with pacemakers or defibrillators
• Malignant superior vena cava syndrome
• Gross obesity
• History of prior catheterization of the subclavian vein
• Patient refusal to participate in the study.

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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80 participants in 2 patient groups

Right subclavian vein cannulation

Other group

Description:

All patients will be in supine position, with the right arm abducted to 45 degrees , the angle of the arm will be increased to 90 degrees to best acquire the image. The probe will be placed in he parasagittal plane in the deltopectoral groove of the right side , medial to the coracoid process . The image will be optimized for the best image of the right axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the right axillary vein . The needle will be introduced in real time imaging , in an in plane technique and blood will be aspirated , the guidewire will be introduced in real time imaging. The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin.

Treatment:

Procedure: Ultrasound guided right infraclavicular approach of subclavian vein cannulation

Left subclavian vein cannulation

Experimental group

Description:

All patients will be in supine position, with the left arm abducted to 45 degrees , the angle of the arm will be increased to 90 degrees to best acquire the image. The probe will be placed in he parasagittal plane in the left deltopectoral groove medial to the coracoid process . The image will be optimized regarding the depth , focus and the gain accordingly for the best image of the axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the left axillary vein . The needle will be introduced in real time imaging , in an in plane technique and blood will be aspirated , the guidewire will be introduced in real time imaging. The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin.

Treatment:

Procedure: Ultrasound guided left infraclavicular approach of subclavian vein cannulation