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Axillary Vein Puncture Pacing

Figure 5.6. Anatomy of the subclavian venous system. A: Anatomy of the subclavian venous system and skeletal landmarks relevant to percutaneous access. The subclavius muscle and costoclavicular ligament complex are shown between the clavicle and first rib. Accessing the subclavian vein medially requires the lead to pass through these structures. This may be associated with a higher risk of lead fracture due to compressive forces on the lead. By accessing the cephalic vein or axillary vein (asterisk) extrathoraci-cally it eliminates the problems of lead entrapment. B: Fluoroscopic guidance of introducer needle into the axillary vein. The peripheral venogram delineates the axillary vein as it crosses the first rib (dotted line) in anteroposterior projection. The introducer needle is seen indenting the axilllary vein just before puncture at a site that is far outside the thoracic cage.

Figure 5.6. Anatomy of the subclavian venous system. A: Anatomy of the subclavian venous system and skeletal landmarks relevant to percutaneous access. The subclavius muscle and costoclavicular ligament complex are shown between the clavicle and first rib. Accessing the subclavian vein medially requires the lead to pass through these structures. This may be associated with a higher risk of lead fracture due to compressive forces on the lead. By accessing the cephalic vein or axillary vein (asterisk) extrathoraci-cally it eliminates the problems of lead entrapment. B: Fluoroscopic guidance of introducer needle into the axillary vein. The peripheral venogram delineates the axillary vein as it crosses the first rib (dotted line) in anteroposterior projection. The introducer needle is seen indenting the axilllary vein just before puncture at a site that is far outside the thoracic cage.

Briefly, the axillary vein can be accessed by "blind" venipuncture without venography by entering the pectoral muscle with the access needle just medial to the acromion process on anteroposterior fluoroscopy. The needle is then directed under fluoroscopy to the point at which the lateral border of the first rib appears to cross the inferior margin of the clavicle (Fig. 5.6).The needle approach is angulated to a degree that the first rib is struck with the needle if the vein is not entered. By walking the needle up and down the first rib on repeated passes, the axillary vein is eventually entered. Alternatively, venography readily delineates the course of the vein and may allow for access of the vein far lateral to the first rib (see Fig. 5.6).The most common problem is too shallow an approach to the vein so that the needle passes anteriorly to the vein without entering it. The routine use of venography is valuable when learning this technique.

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