How to make the axillary vein larger? Effect of 90° abduction of the arm to facilitate ultrasound-guided axillary vein puncture ☆ Mauro Pittiruti, MD a , Daniele Guerino Biasucci, MD b, ⁎, Antonio La Greca, MD a , Alessandro Pizza, MD b , Giancarlo Scoppettuolo, MD c a Department of Surgery, “A. Gemelli” Teaching Hospital, Catholic University of the Sacred Heart, Rome, Italy b Department of Intensive Care Medicine and Anesthesia, “A. Gemelli” Teaching Hospital, Catholic University of the Sacred Heart, Rome, Italy c Department of Infectious Diseases, “A. Gemelli” Teaching Hospital, Catholic University of the Sacred Heart, Rome, Italy abstract article info Keywords: Axillary vein Central venous catheterization Ultrasound guidance Purpose: Placement of central venous catheters by the infraclavicular route can be achieved by ultrasound-guided puncture of the axillary vein. However, in some cases, the axillary vein may be difficult to puncture because it is too deep or too small or because it is collapsing significantly during breathing. The objective of this observational study was to determine the effect of 90° abduction of the arm associated with forward position of the shoulder on axillary vein diameters. Material and methods: In a group of 30 healthy volunteers and in a group of 40 patients during spontaneous breathing, we used ultrasound to examine the axillary vein, visualizing it in short axis, with the arm at 0° and at 90° abduction, pushing the shoulder forward. Results: The axillary vein was easily identified in 100% of subjects, with relevant variability in terms of depth from the skin, diameter, and tendency to collapse during inspiration. Significant increase of axillary vein diameters was found after 90° abduction in 52 of the 70 cases studied. Conclusion: These findings suggest that a 90° abduction of the arm, particularly if associated with a forward position of the shoulder, facilitates the visualization of the axillary vein, making its ultrasound-guided venipuncture easier. © 2016 Elsevier Inc. All rights reserved. 1. Introduction 1.1. Background and rationale Ultrasound-guided puncture and cannulation of the axillary vein (AV) in the infraclavicular area has several potential advantages for both short-term and long-term venous access devices (VADs): in short-term central VADs, the exit site is easier to manage in terms of dressing and securement; in long-term central VADs, the infraclavicular approach is associated with shorter tunnel (in the case of cuffed tunneled catheters) or no need of tunnel (in the case of totally implant- able venous ports), thus increasing the stability of the system and avoiding the subcutaneous passage of the catheter over the clavicle. In most patients, AV can be easily visualized both in short axis (transverse diameter) and in long axis (longitudinal diameter) [1,2], and it can be punctured either “in plane” or “out of plane” [1,2]. However, in some cases, AV may be difficult to puncture because it is too deep or too small, or because it is collapsing significantly during spon- taneous breathing. Moving the probe downward (far from the clavicle), the transverse diameter of the AV becomes smaller and the vein collapse during inspiration more relevant, thus making the puncture even more dif- ficult. Cadaver-based studies have been shown that the position of the arm affects the position of AV [3]. Galloway and Bodenham [4] have suggested that different degrees of abduction of the arm may have only limited ef- fects on AV diameter, although some episodic clinical observations have suggested that the diameter of AV may be increased by the abduction of the arm at 90° if associated with a forward displacement of the shoulder. 1.2. Objective The objective of this prospective nonrandomized observational study was to assess the effect of 90° abduction of the arm—associated with forward position of the shoulder—on the ultrasound visualization of the AV in terms of main diameter and estimated depth. 2. Material and methods This is a single-center, prospective, nonrandomized observational study which was conducted in a large university hospital in Rome Journal of Critical Care 33 (2016) 38–41 ☆ Conflict of interests and source of funding: All authors confirm that there are no known conflicts of interest associated with this publication and that there has been no fi- nancial support for this study that might have influenced its outcome. ⁎ Corresponding author at: Department of Intensive Care Medicine and Anesthesia, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy. Tel.: +39 06 30154848. E-mail address: danielebiasucci@gmail.com (D.G. Biasucci). http://dx.doi.org/10.1016/j.jcrc.2015.12.018 0883-9441/© 2016 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Critical Care journal homepage: www.jccjournal.org