INTRODUCTION

Patients with acute (ARF) or chronic (CRF) frequently need the use of central venous catheters to receive hemodialysis therapy. The approach through the femoral vein is the most commonly used to perform acute hemodialysis given its low rate of complications although it has the drawback that it should not be placed for longer than 8 days, mainly because of the risk form infectious complications. The internal jugular veins are the ideal route for placing catheters for longer than 8 days because they may be used for a long time and have not major complications. The route through the subclavian vein has been abandoned by most of the nephrologists due to the complications associated to the canalization procedure (hemothorax and pneumothorax) and the risk for generating infraclavicular venous stenosis, which will further prevent the creation of properly patent arterial-venous fistulas.1

Sometimes, an mainly when the patients present infectious complications or catheter malfunctioning due to thrombosis, it is necessary to frequently replace them, which leads to fibrosis within the supraclavicular regions preventing further use of the jugular veins for hemodialysis. In patients in the ICU, respiratory support is commonly needed so that, if prolonged, they will require a tracheotomy to avoid the occurrence of tracheal stenosis, with the generation of abundant secretions that contaminate the in-let of jugular or subclavian catheters.

In the last two situations, it is then necessary to use a different route to place a central catheter that will allow continuing with the dialysis therapy required by the patient.

The axillary vein route has been used for many years in patients at intensive care units to place central catheters with purposes different from dialysis, with good results. This led me to review the anatomy of the axillary or infraclavicular region, and initially following anatomical references2 and later on through palpation of the axillary artery I decided to place axillary catheters for hemodialysis in a group of patients presenting the characteristics described. My personal experience with this kind of procedure will be reported next.

MATERIALS AND METHODS

From May of 1997 to May of 2007, patients with ARF or CRF were identified at Intensive Care Units or at the Renal Therapy Department of Caldas (Manizales-Caldas-Colombia-South America), meeting one of the two requirements to try the canalization of the subclavian vein: 1) The impossibility of placing a central catheter through the internal jugular veins; 2) Tracheotomy for respiratory support for the underlying disease. They (or their family) were proposed to place a bi-lumen central catheter for hemodialysis, which was always placed first in the femoral vein, but after 8 days or before in the presence of catheter-related infectious complications it was removed, suggesting puncturing the axillary vein with anatomic guidance or by palpation to place a longer-lived catheter. Those patients accepting and giving their written consent (or the family consent) were submitted to the procedure, with radiological confirmation of proper location, and establishing the catheter functioning with time, and recording the procedure-associated complications and the catheter permanence. The technique applied in those cases with anatomical guidance was that proposed by Taylor and coworkers,3 in which it is presumed that the axillary vein lies at a distance of three fingers below the coracoid process, and entering for puncturing from below and upwards, and always avoiding advancing the needle under the collarbone (in which case the subclavian vein would be punctured) in order to avoid major complications. The procedure was done under local anesthesia or with assisted sedation in ventilated patients and using the classical Seldinger¿s technique.

RESULTS

Twenty-six patients (9 women and 17 men) met the established requirements, with a mean age of 54.6 years. The etiology of acute or chronic renal failure is summarized in Table 1. In two patients we could not puncture the axillary vein, and in the patients remaining 25 axillary catheters were placed: 1 permanent and 24 temporary; in one patient a temporary catheter was used as a guide to place a permanent one later on. The technique was done by anatomical guidance in 16 patients and by palpation in 8, highlighting that the latter technique was only achieved in recent years thanks to the skills developed by the operator. Ultrasound guidance was used in no patient to perform the procedure.

Fifteen left axillary veins and 10 right axillary veins were channeled, and the reason for requiring this procedure was: impossibility to canalize the internal jugular veins in 19 patients (fig. 1), and because of carrying a tracheotomy in 7 patients (fig. 2). Satisfactory location was radiographically confirmed (fig. 3) in 24 procedures (96%), and only one patient showed advance of the catheter to the right jugular vein, without being able to relocate the catheter in spite of the use of fluoroscopic methods, being the reason why we decided to remove it. The mean time the catheters were in use was 68.6 days, currently one is still working, and the remaining were removed due to: transfer to peritoneal dialysis (6 patients), intra-hospital death,6 satisfactory use of arterial-venous fistula,4 renal function recovery,4 switch to permanent catheter,1 catheter-induced sepsis,1 and catheter malfunctioning after 30 days.2 The axillary artery was accidentally punctured in 3 procedures (12%), one of which led to soft tissue haematoma without hemodynamic repercussion and with spontaneous resolution within few weeks; of the two patients in whom the axillary vein could not be canalized, one was diabetic with severe diffuse vascular compromise, and the other one was a female patient with morbid obesity. There were no other complications such as pneumothorax or paresthesia due to puncture of the brachial plexus.

DISCUSSION

Hemodialysis patients frequently require the use of central venous accesses to receive dialysis; the accesses located in the neck region are the most frequently used ones in the longterm, the most popular being the internal jugular and the subclavian veins.4 The latter is used less frequently in recent years given the risk for generating jugular vein stenosis, which blocks the draining blood flow of the upper limb limiting its use for further arterial-venous fistulae, and the common complications associated with the procedure, which some of them may even compromise the patient¿s life.1 Other less used alternatives in the neck are the puncture of the innominate vein, with which some experiences have been reported,5, 6 and none using the axillary vein, underlining that these two latter situations may only be tried when the classical methods have been ruled out.

Axillary veins arise from the axillary fold and proceed into the subclavian vein at the lateral rim of the first rib (fig. 4), and have classically been divided into three segments: proximal, posterior, and distal with regards to the pectoris minor muscle, and its location is completely extrathoracic; its canalization is difficult since it requires to penetrate all the width of the pectoris major muscle (fig. 5) and palpation is difficult in little skilled hands and in edematous patients or with large adipose panicle; so, its puncture requires either appropriate knowledge of the infraclavicular regional anatomy or getting experience in palpating it. Recently, ultrasound guidance has allowed detecting the axillary veins more easily and accurately, observing that they are located a little bit downwards and close to the axillary arteries,7-9 so that it is common that the latter are punctured when trying to canalize the veins. We should underline that the further we go away from the sternum the more the axillary vein separates from the axillary artery and the posterior brachial nerve plexus, although its diameter gets smaller and its location deeper, while increasing the safety margin for puncturing it.10

Experiences puncturing the axillary veins at the axilla were already described in the year 1967,11 although they were associated with a high infection rate12 due to the high variety of bacteria colonizing this area, as has been shown in patients with severe burns in whom this may be the only territory free from burns allowing for the placement of a central venous catheter.13

Puncturing the axillary vein has the advantage of avoiding the complications described for accesses through the internal jugular and subclavian veins;14-17 moreover, in case of puncturing the axillary artery applying pressure on it for a short period of time prevents the occurrence of big hematomas, by contrast to what happens at the other deeper locations mentioned that do not allow this maneuver. For several decades, the canalization of this access has been used at Critical Care Units with good results;9 it is interesting not to find any publication on this matter within the Nephrology field.

In this case report, we found that in only two patients (7.6%) out of 26 needing the use of a route different from the usual one it was not possible to puncture the axillary vein; in the remaining patients in whom the goal was achieved, in only one (3.8%) the catheter followed an abnormal route and in 3 (12%) the axillary artery was punctured without the occurrence of important hematomas, while achieving a good catheter functioning in most of the patients, with an average working time of 2 months.

The purpose of this work was to present the author¿s experience in channeling this route, which has not been described for hemodialysis until now, in order to obtain a central venous access when the use of other routes is unfeasible or little practical; we do not intend to compare this with other experiences using the usual routes, which have shown their benefit in large published series to date.