Comparison of the proximal and distal approaches for axillary vein catheterization under ultrasound guidance (PANDA) in cardiac surgery patients susceptible to bleeding: a randomized controlled trial

Ying Su, Jun-Yi Hou, Guo-Guang Ma, Guang-Wei Hao, Jing-Chao Luo, Shen-Ji Yu, Kai Liu, Ji-Li Zheng, Yan Xue, Zhe Luo, Guo-Wei Tu, Ying Su, Jun-Yi Hou, Guo-Guang Ma, Guang-Wei Hao, Jing-Chao Luo, Shen-Ji Yu, Kai Liu, Ji-Li Zheng, Yan Xue, Zhe Luo, Guo-Wei Tu

Abstract

Background: The present study aimed at comparing the success rate and safety of proximal versus distal approach for ultrasound (US)-guided axillary vein catheterization (AVC) in cardiac surgery patients susceptible to bleeding.

Methods: In this single-center randomized controlled trial, cardiac surgery patients susceptible to bleeding and requiring AVC were randomized to either the proximal or distal approach group for US-guided AVC. Patients susceptible to bleeding were defined as those who received oral antiplatelet drugs or anticoagulants for at least 3 days. Success rate, catheterization time, number of attempts, and mechanical complications within 24 h were recorded for each procedure.

Results: A total of 198 patients underwent randomization: 99 patients each to the proximal and distal groups. The proximal group had the higher first puncture success rate (75.8% vs. 51.5%, p < 0.001) and site success rate (93.9% vs. 83.8%, p = 0.04) than the distal group. However, the overall success rates between the two groups were similar (99.0% vs. 99.0%; p = 1.00). Moreover, the proximal group had fewer average number of attempts (p < 0.01), less access time (p < 0.001), and less successful cannulation time (p < 0.001). There was no significant difference in complications between the two groups, such as major bleeding, minor bleeding, arterial puncture, pneumothorax, nerve injuries, and catheter misplacements.

Conclusions: For cardiac surgery patients susceptible to bleeding, both proximal and distal approaches for US-guided AVC can be considered as feasible and safe methods of central venous cannulation. In terms of the first puncture success rate and cannulation time, the proximal approach is superior to the distal approach. Trial registration Clinicaltrials.gov, NCT03395691. Registered January 10, 2018, https://ichgcp.net/clinical-trials-registry/NCT03395691?cond=NCT03395691&draw=1&rank=1 .

Keywords: Axillary vein; Central venous access; Central venous cannulation; Longitudinal axis; Subclavian vein.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Illustration of proximal axillary (left) and distal axillary (right) approaches. a, b Diagrammatic drawings of the anatomical views of proximal (a) and distal (b) approaches for ultrasound-guided axillary venous catheterization. c, d Ultrasound visualization of the guide wire in the proximal (c) and distal (d) axillary veins. e, f catheter in place secured to the skin in proximal (e) and distal (f) approaches. The inferior margins of the clavicle are drawn in e and f, where the mid-clavicular point and the medial and lateral one-third of the clavicle are marked. White arrows show the guide wire. Black asterisk indicates the anticipated skin puncture site of the distal approach and black triangle indicates the anticipated skin puncture site of the proximal approach. C, clavicle; depth, the distance between skin surface and the anterior wall of vein; diameter, anteroposterior diameter of the vein
Fig. 2
Fig. 2
CONSORT flow diagram. ITT, intention-to-treat

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