Axillary vein access with or without venography: is this the dilemma in the ultrasounds era?—Authors’ reply

We thank Dr De Sensi et al.1 for their comments on our study comparing cephalic vein and blinded axillary vein access for pacemaker implantation.2 We also believe that venography for axillary vein access should be avoided for several reasons. First, intravenous contrast injection has a potential for anaphylaxis, and for renal failure in predisposed patients. Second, it necessitates a peripheral venous catheter on the ipsilateral arm, which could be an entry site for bacteraemia and, thus, could increase the risk of device infection. Finally, as mentioned by De Sensi et al., the visualization of the vein occurs before but not during the puncture, and doesn’t provide any information regarding the vessel depth. The main question that remains is whether we should, or not, always guide the axillary puncture with ultrasound imaging. Even if ultrasound guidance can facilitate the axillary vein access (like for any central vein), the so-called ‘blinded’ puncture, using anatomical landmarks such as the anterior part of the first rib, remains very quick and uncomplicated in the vast majority of patients. Rarely, puncture of the axillary artery occurs, but no pocket haematoma has been observed in our study in case of arterial puncture. Also, we did experience two cases of transient brachial plexus palsies, quickly recovering without sequels. It should be emphasized that these two cases of brachial plexus palsies occurred in our very early experience of axillary vein puncture, because of too lateral punctures. We did not experience anymore brachial plexus palsies during the last 2 years, highlighting the influence of the training period on this benign and transient complication. Nevertheless, some patients could especially benefit from ultrasound guidance. In very old patients with bone demineralization, the anterior part of the first rib can be difficult to see using fluoroscopy, and there is a risk of pneumothorax if the rib is missed and the lung punctured. Also, in patients with atypical chest anatomy or with extreme body mass index, accessing the axillary vein using standard anatomical landmarks can be difficult. To conclude, we believe that if an ultrasound machine is readily available in the operating room, it could be used for every patient to facilitate axillary vein access, provided that special care is given not to compromise the sterile field with the additional manoeuvres required by ultrasound guidance. In centres, where an ultrasound machine is not readily available in the operating room, it might be useful to specially organize the procedure with ultrasounds in patients with bone demineralization or atypical chest anatomy. Conflict of interest: none declared.