Cephalic Vein Made Easy

The cephalic vein is suitable for central venous access and pacemaker and defibrillator implantation. Furthermore, with a success rate of approximately 80 percent, the cephalic vein cut-down method is associated with a lower probability of complications than the subclavian puncture. A 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 

The deltopectoral groove is identified by a strip of fat between two muscles (deltoid and pectoralis major) in which the cephalic vein is embedded. 

Topography and Distribution Pattern 

The cephalic vein is found in 95 percent of patients. In 80 percent of patients, the cephalic vein emerges superficially in the lateral portion of the deltopectoral triangle. In 20 percent of patients, 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 

Surgically expose the deltopectoral groove and the cephalic vein, followed by puncturing of the cephalic vein and implantation of the 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, tortuosity), 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 deltopectoral groove, puncture and sheath introduction is fast and easy. Many studies and meta-analysis have shown that the use of the cephalic vein was associated with a lower risk of pneumothorax, hemothorax, and lead failure (subclavian crush injury) compared with puncture of the subclavian vein (1).  

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

1. 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.
2. 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.
3. 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.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.