Intra-pocket ultrasound-guided axillary vein puncture group
transducer
STERILE
In the IPUS-AVP group, after preparation of the sterile field, an L-shaped ‘hockey stick’ small-footprint US transducer (L8–18i probe, General Electric Healthcare, Boston, MA, USA), linked to an US scanner (Vivid T8, General Electric Healthcare), was handed to the operator in a sterile way and placed in a sterile sheath with gel inside. The US probe is presented in Illustration of the intra-pocket ultrasound-guided axillary vein puncture technique. (A) ‘Hockey stick’ ultrasound transducer. (B) Transducer and needle configuration for ultrasound-guided axillary venous puncture. The operator is on the left side of the patient. The transducer is held with the left hand and the needle with the right hand. (C) Cross-sectional view of axillary vein (AV) and artery (AA). The lung (L) is also visualized. (D) Needle tip (solid white arrow) is seen advancing in the axillary vein. (E) Needle tip (dashed white arrow) is seen in the lumen of the vein.After local anaesthesia, an incision was made 1 cm medial to the deltopectoral groove, subcutaneous tissues were dissected down to the pectoral muscle, and a subcutaneous pocket was created for the generator. The US probe was then placed in contact with the pectoral muscle, perpendicularly to the axis of the axillary vessels. Saline was used as the US contact medium. Venous access was performed through IPUS-AVP and Seldinger technique with an 18G needle attached to a syringe (After successful puncture, a 0.035″ J-tipped guidewire was inserted and advanced to the SVC under fluoroscopy guidance. A standard tear-away sheath according to the size of the lead was inserted over the guidewire. If multiple leads were implanted, the operator was required to perform a distinct puncture for the second sheath and not use a retained guidewire technique. After all guidewires were inserted into the vein and visualized in the SVC under fluoroscopy guidance, the US probe was removed from the sterile field. A video illustrating the technique is available as In case of failure with IPUS-AVP, the protocol specified that CVC should be performed in the second line, and then an SVP in the last intention.