Cephalic Vein Made Easy

The cephalic vein is suitable for central venous access, pacemaker and defibrillator implantation. Furthermore, the cephalic vein cut-down method is associated with a lower incidence of complications than subclavian puncture with a success rate of approximately 80%. The surgeon’s ability to recognize and identify the anatomical variations of the cephalic vein will reduce the occurrence of iatrogenic complications when surgery is performed in and around the deltopectoral triangle.

Surgical anatomy:

- Deltopecttoral groove - identified by a strip of fat between two muscles (Deltoid and Pectoralis major) in which the cephalic vein is embedded.

Topography and distribution pattern:

- Cephalic vein is found in 95% of patients and absent in 5%.

- 80%: Cephalic vein is emerging superficially in the lateral portion of the deltopectoral triangle.

- 20%: It does not emerge through the deltopectoral triangle but is identified medially to the coracobrachialis and inferior to the medial border of the deltoid.

Technique:

- Surgical exposure of deltopectoral groove and the cephalic vein.

- Puncture of the cephalic vein , implantation of 7F-9F sheath in Seldinger-Technique (see the video).

Tips and tricks:

- Avoid significant manipulation of the vein as the vessel is prone to spasm.

- If advancing the standard wire is not possible (small vein, turtuousity),use Terumo® wire.

Conclusion:

- Cephalic vein cutdown and subclavian vein puncture are both widely used techniques for lead insertion in clinical practice. However, the use of one technique over the other is largely limited by operator experience and local practice patterns.

- After surgical exposure of the vein in the delptopectoral groove , puncture and sheath introduction is fast and easy.

- Many studies and meta-analysis showed that the use of cephalic vein was associated with a lower risk of pneumothorax , haemothorax and lead failure (subclavian crush injury) compared with puncture of the subclavian vein (Atti et al. 2020, A.P. Benz et al. 2019).

- In majority of patients, cephalic vein is the best way for implantation of pacemaker and defibrillator leads and should be considered as the first choice.

References

Atti V, Turagam MK, Garg J, Koerber S, Angirekula A, Gopinathannair R, Natale A, Lakkireddy D. Subclavian and Axillary Vein Access Versus Cephalic Vein Cutdown for Cardiac Implantable Electronic Device Implantation: A Meta-Analysis. JACC Clin Electrophysiol. 2020 Jun;6(6):661-671. doi: 10.1016/j.jacep.2020.01.006. Epub 2020 Mar 16. PMID: 32553216.

Benz AP, Vamos M, Erath JW, Hohnloser SH. Cephalic vs. subclavian lead implantation in cardiac implantable electronic devices: a systematic review and meta-analysis. Europace. 2019 Jan 1;21(1):121-129. doi: 10.1093/europace/euy165. PMID: 30020452.

Loukas M, Myers CS, Wartmann ChT, Tubbs RS, Judge T, Curry B, Jordan R. The clinical anatomy of the cephalic vein in the deltopectoral triangle. Folia Morphol (Warsz). 2008 Feb;67(1):72-7. PMID: 18335417.