The Next Time A Peripheral Arterial Line is Not Feasible Consider Placing a Catheter in the Axillary Artery
Susan Nicolson, James DiNardo, Viviane Nasr, Lindsey Loveland
Original article
Zaleski KL, Kuntz MT, Staffa SJ, Van Pelt H, Hamilton ARL, Atkinson DB. Central Arterial Line Placement for Pediatric Cardiac Surgery: A Single-Center Experience. Anesth Analg. 2024 Jun 27. doi: 10.1213/ANE.0000000000006972. Epub ahead of print. PMID: 38935540.
Children undergoing cardiac surgery require constant hemodynamic monitoring throughout the perioperative period. Invasive arterial access enables continuous blood pressure monitoring and accessible blood sampling. Peripheral cannulation using the radial artery is commonly used due to high success and low complication rates.1 When anatomic, physiologic and/or patient factors make peripheral cannulation unfeasible, cannulation of central arteries, axillary or femoral, becomes necessary. Little data exists to guide site selection beyond the radial artery in pediatric patients undergoing cardiac surgery.
Zaleski et al.2 retrospectively reviewed pediatric patients who underwent intraoperative placement of an axillary or femoral arterial line between July 2012 and June 2022 at a single large volume cardiac program (Boston Children’s Hospital). The primary aim was to quantify the rate of complications associated with central arterial line placement. Complications were defined as pulse loss, vascular compromise, or catheter associated infection. Pulse loss was defined as a documented absence of a detectable pulse by Doppler distal to the arterial line. Vascular compromise was defined as any perfusion abnormality, including documented pulse loss, ultrasound findings consistent with arterial thrombus or flow abnormality, and/or examination asymmetry (pulse, color, or temperature) with the contralateral limb. Secondary aims were to: 1) determine risk factors associated with central arterial line complications and 2) describe placement trends over the time of the study.
A total of 1263 central arterial lines were placed in 1135 patients with 195 (15.4%) placed in the axillary artery and 1068 (84.6%) in the femoral artery. There was a significant shift from femoral to axillary placement (p< .001) during the decade of the study period, from 0% to 50% of central lines placed annually (Figure).
Patients who underwent axillary arterial line placement were younger, smaller, and more likely to have a history of prematurity and to have an attending anesthesiologist place the line.
There were 17 different types of catheters used and catheter selection was different between groups. The most common catheter size used for axillary artery lines were 24 G (66%) and 2.5F (23.4%). The most common catheters used in the femoral group were 2.5 F (46.2 %) and 3.5F or 20 G (33.8%).
The overall incidence of vascular compromise and pulse loss was 17.8% and 8.3%, respectively. The incidence of vascular compromise and pulse loss were lower for lines placed in the axillary artery (6.2% and 2.1% respectively) than for those placed in the femoral artery (19.9% and 9.5% respectively) despite the patients being younger, smaller and with a higher ASA physical status.
Multivariable logistic regression analysis identified several independent risk factors for both vascular compromise and pulse loss: presence of a genetic syndrome, prematurity, smaller patient size, femoral location, larger catheter size and longer anesthesia time.
Major complications, threatened limb, amputation, large abdominal wall hematoma, occurred in only 4 patients, all in the femoral line group.
Line outcomes are shown in Table 1.
Axillary cannulation offers a theoretical advantage over femoral cannulation due to the extensive collateral flow to the distal arm via the thyrocervical trunk and branches of the subclavian artery that anastomose around the scapula. Axillary lines are ideally placed in the 2nd portion of the artery where the vessel is compressible proximally, lacks critical branches or overlying neural structures, and is a safe distance from the thorax, minimizing the potential for pneumothorax.
Axillary arterial access was associated with a lower rate of complications in pediatric patients undergoing cardiac surgery as compared to femoral access. Serious complications were rare and were limited to femoral arterial lines in this study. Pediatric anesthesiologists should consider axillary line placement using ultrasound in situations where peripheral arterial cannulation is not possible or central arterial cannulation is preferable. Further investigation is needed to: 1) determine if these results are reproducible in other centers, 2) compare the size of the axillary and femoral arteries in infants and small children and 3) assess the impact of risk mitigations strategies on complications with central arterial access.
Send your thoughts and comments to Myron who will post in a Friday reader response.
PS from Myron: Many of you may be unfamiliar with how to convert French size to Gauge size (or vice versa). Needles and single lumen peripheral IV catheters are usually sized in Gauge and multi-lumen or central lines in French. A calculator I find helpful was developed at Cornell University’s Pediatric Critical Care Division http://www-users.med.cornell.edu/~spon/picu/calc/gafrconv.htm
References:
1. Gleich SJ, Wong AV, Handlogten KS, Thum DE, Nemergut ME. Major Short-term Complications of Arterial Cannulation for Monitoring in Children. Anesthesiology 2021;134(1):26-34. (In eng). DOI: 10.1097/aln.0000000000003594.
2. Zaleski KL, Kuntz MT, Staffa SJ, Van Pelt H, Hamilton ARL, Atkinson DB. Central Arterial Line Placement for Pediatric Cardiac Surgery: A Single-Center Experience. Anesthesia and analgesia 2024 (In eng). DOI: 10.1213/ane.0000000000006972.