JSUR Journal

Introduction

The first available description of the Cephalic Vein (CV) was proposed in the 2nd century AD by Galen of Pergamon who transposed his observations made on monkeys onto humans and claimed that the CV (Galen’s humeral vein) “arose” from the external jugular vein and encircling the clavicle “ran towards the periphery” [1]. The CV as a term originates from the Arabic word al-kefal, which means “outer” and was first used by Muslim physician Abu Ali al-Hossein ibn Adbullah Ibn Sina (known as Avicenna in the West), when the term was translated to Latin, cephalic inaccurately was selected to replace the Arabic origin of the term [2]. Until the last decade of the 20th century, most studies of the cephalic veins were anatomical and were performed on cadavers [3] or with intraoperative venography [4], while ultrasound is the most widely used technique nowadays [5]. Since the beginning of pacemaker implants in 1959 [6] and Totally Implantable Venous Access Port (TIVAP) in 1982 via the Cephalic Vein Cutdown (CVC) approach [7], this is the access route with the fewest intra- and postoperative complications, although due to variations in caliber and depth in the deltopectoral groove (DG), as well as other possible anomalies, a success rate of 71.0% has been reported [8]. Hence the importance of identifying the exact anatomy.

Materials and Methods

In January 2008, our Department of Angiology and Vascular Surgery´s Outpatient Clinic began performing a preoperative Doppler ultrasound on all patients referred by the Oncology Department for the implantation of a TIVAP for chemotherapy treatment. Although the first choice for implantation is the Left Cephalic Vein (LCV), except in left-handed patients, those who had undergone breast surgery on the left side with/without axillary lymphadenectomy or previous TIVAP/pacemaker implanted on this side, assessment of CVs in both DGs were made. During the outpatient clinic and with the patient in supine position the CV is displayed by means of a 7.5 – 12 MHz probe of MyLab50 and MyLabX5 (Esaote, Genoa, Italy) colour Doppler ultrasound at the level of both DGs, registering its diameter, depth, course, drainage of the CV to AV junction (CV/AV), as well as the patency of the AV. The CV diameter (in millimeters) is considered as the maximum transverse measurement in its course up to the CV/AV junction. CV depth as the distance (in millimeters) between the skin and its upper edge in its closest portion to the skin.

The CV was classified by its size into absent (when not visible), small (diameter < 3.0 mm) and normal (diameter ≥ 3.0 mm). This classification is used because the TIVAP implantation system is a NuPport HP* device (PHS MEDICAL - Fuldabrück, Germany) with a single-chamber titanium port and a silicone catheter with an external diameter of 9.6 F (≈ 3.0-3.2 mm). CV stenosis is defined as a narrowing of the vessel lumen of more than 50% of the total. The absence of flow signals in the AV with intraluminal echogenic material is considered as venous thrombosis. Figure 1 shows the different parameters assessed in this study.

The surgical procedure for the implantation of TIVAP is always performed through a 3-4 cm single incision in the DG via CVC or Infraclavicular Subclavian Vein Puncture (SVP). The CVC surgical technique is perfectly described by Jouvin [9]. If the CV is small or there is a partial stenosis of the CV/AV junction, sometimes the venous access is possible with the help of a Micropuncture Kit (AngioDynamics - Latham, USA) with a 21-Gauge needle an a 0.018′′ guidewire. When the CV is absent or not suitable, the TIVAP is placed through SVP using the Landmak technique [10]. Ultrasound studies and surgical techniques for TIVAP insertion and removal were performed by the same vascular surgeon with 35 years of experience in this field. The data obtained were recorded in a FileMaker Pro database. All patients provided signed informed consent for the procedures.

Statistical Analysis

The baseline characteristics of the study groups were described using means with their corresponding Standard Deviations (SD) for continuous variables and frequencies and percentages for categorical variables. Boxplots were plotted and medians and Interquartile Ranges (IQR) were computed in order to see differences in numerical variables distributions. Differences between sex were compared according to sociodemographic and clinical variables. If the compared variable was numerical, Wilcoxon rank-sum test was used for non-normally distributed data; if the variable was categorical, Chi-squared or Fisher’s exact test was used, as appropriate. Differences between left and right veins were compared by Wilcoxon signed-rank test for related samples or by McNemar test depending on the nature of the compared variable. Statistical significance was set at P value ≤ 0.05 and statistical analysis were performed by using RStudio^® version 4.3.1.

Results

Between January 2008 and December 2023 a total of 2400 CVs in the DGs of 1200 patients were studied with ultrasound before the implantation of the TIVAP, 744 (62.0%) of whom were women. The mean age was 63.3 years (SD: 11.6). Table 1 details the general characteristics of all patients. Men were significantly older and had a higher incidence of colorectal, digestive and laryngeal cancers, while breast cancer was significantly more common in women.

Table 1: General characteristics.

SD: Standard Deviation

Of 2400 CVs scanned with ultrasound, in 30 occasions (2.5%) the CV was not visualized on either side, in 17 (1.4%) the right CV (RCV) was not found, and in 78 (6.5%) the LCV was not found. Excluding absent CVs, the mean diameter of CVs was 3.8 mm (SD: 0.5) and the mean depth was 13.6 mm (SD: 2.9). Table 2 shows the distributions of the CVs, comparing the findings between the two sides. The mean CV diameter and depth were similar on both sides. Although not reaching statistical significance, the number of CVs ≥ 3.0 mm was higher on the left side. Ninety-one (4.1%) stenosis at the CV/AV junction were observed, which were significantly more frequent in the LCVs. Tortuosity was found in 32 CVs (1.4%), all of them in CVs with diameters < 3.0 mm, with LCVs being the most significantly affected. AV thrombosis was found on 22 occasions (1.0%). Significant differences were not found between sexes for AV occlusion. Additionally, during the 2057 dissections of CVs ≥ 3.0 mm, 45 (2.2%) venous spasms occurred, 16 (2.0%) in RCVs and 29 (2.3%) in LCVs. The median ultrasound scan time per vein was 2.2 ± 1.1 minutes.

SD: Standard Deviation - RCV: Reigh Cephalic Vein – LCV: Left Cephalic Vein – AV: Axilar Vein 

The Wilcoxon signed-rank test for related samples showed (4.0 mm), differences between both sides were observed as the differences between the diameter and depth distributions of the diameters were smaller in the RCVs than in the LCVs (Q1 3.5 mm CVs assessed (Figure 2). Although the median diameters of the versus Q1 3.7 mm). The median depth was significantly higher in RCVs and LCVs were similar (3.8 mm), as was the third quartile the RCVs (Q1 13.9 mm vs. 13.4 mm).

Figura 2: Box plot representation of CV diameter (mm) and depth (mm), comparing both sides.

Table 3 shows that CVR is absent in a higher percentage of women, sexes, by side of vein, no significant differences were found in the being statistically significant. CVs diameter and depth on both other variables sides were significantly greater in men. When comparing between

Table 3: CV distribution on both sides and sexes, except for CVs absent.

SD: Standard Deviation; RCV: Reigh Cephalic Vein; LCV: Left Cephalic Vein; AV: Axilar Vein

In Figure 3 shows the same results: the median CVs diameter was 15 mm (IQR: 12mm – 16mm) in men versus 13 mm in women significantly higher in men (3.9 mm [IQR: 3.7 mm - 4.1 mm]) (IQR: 11 mm – 15 mm). versus women (3.8 mm [IQR: 3.6 mm - 4.0 mm]) as was the depth:

Figure 3: Box plot representation of CV diameter (mm) and depth (mm), comparing both sexes.