VADs (Vascular Access Devices) can be inserted in various areas of the body via a selection of veins. Some venous access sites can result in more complications. It is therefore important to carefully select the vein for access.

The purpose of this article is to detail and describe the veins most used for access and subsequent vascular access device insertion.

Structure of the vein

Image 1: Structure of the vein

The main function of veins is to carry waste products and deoxygenated blood away from tissues and organs. They help to eliminate waste products from the body and return deoxygenated blood back to the heart for re-oxygenation.

Veins are blood vessels that possess three layers of tissue. They include the tunica intima, tunica media, and tunica externa (Image 1).

The internal layer

The internal layer (tunica intima) is made up of squamous epithelium cells known as endothelium along with a basement membrane and a layer of elastic tissue (internal elastic lamina).

The purpose of the endothelium is to facilitate blood flow along the vessel and to prevent the adhesion of blood cells to the vessel wall (Tortora and Derrickson, 2021). This layer is important when inserting a needle during vascular access, as trauma can disrupt the lining and encourage platelets to adhere to the vessel wall. This can then result in thrombus formation.

There are other factors that can lead to damage of the endothelium cells. These include inserting a device in areas of flexion (such as over joints), poor device securement or dressing which can result in continuous catheter movement and vein intima damage. (Gorski, 2021).

The middle layer

The middle layer (tunica media) is composed of elastic tissue and smooth muscle fibres that run in a circular manner around the lumen of the vein. It also has an external lamina, which consists of elastic tissue (Tortora and Derrickson, 2021). This layer is sensitive to changes in temperature as well as mechanical or chemical irritation and this can cause the vessel to spasm.

It is important to note that this layer is also prone to, what is called, the stress relaxation phenomenon.

Because a tourniquet is used during some catheter insertion procedures, the muscle fibres elongate to accommodate the increased volume of blood. The pressure increases but then reverts to normal. When the tourniquet is subsequently removed, the volume and pressure fall suddenly and, within several minutes, normal pressure is re-established.

Therefore, if an obstruction is encountered during advancement of a cannula or midline, it may mean that adequate time has not been left between tourniquet removal and vein flow recovery time. Tourniquets can also cause veins to become unpalpable if left in place for an extended length of time. This can be due to smooth muscles over-stretching (Hadaway, 2001).

The tunica adventitia

The final layer is the tunica adventitia. This layer is composed of connective tissue, collagen, and nerve fibres. The nerve fibres are fibres of the sympathetic nervous system. The purpose of this layer is to support the vessel (Tortora and Derrickson, 2021).

Valves

Valves are structures found within the veins. They are formed by the endothelial lining of the Tunica Intima and are found in most veins apart from the larger veins of the vasculature. Their function is to allow unidirectional flow of blood back to heart and to prevent pooling in the peripheral circulation.

Valves can be visualised by ultrasound. They can sometimes be palpated. Occasionally valves can cause difficulties when threading guidewires through the veins.

Veins used for short peripheral catheters

Dorsal hand veins

Image 2: Dorsal veins of the hand

The small digital veins flow along the lateral portion of the fingers. The digital veins join to form the dorsal metacarpal veins which are easily visualised and palpated. The dorsal digital veins from the adjacent sides of the fingers unite to form three dorsal metacarpal veins. These form a dorsal venous network opposite the middle of the metacarpus.

The dorsal venous network of the hand lies within the superficial fascia on the dorsum (back) of the hand. The dorsal venous network is formed by the dorsal metacarpal veins which eventually give rise to the cephalic vein and basilic vein.

Although the hand is an area of flexion, these veins remain popular for peripheral venous cannulation as they are often prominent. As previously mentioned, devices placed in areas of flexion can irritate and damage the intima of the vein, potentially resulting in mechanical phlebitis.

Forearm veins

The superficial venous arch in the dorsum of the hand drains into the cephalic vein and basilic vein (Image 2).

The basilic vein in the forearm is usually a large vein. It is sometimes overlooked because of its position on the posterior medial aspect of the forearm. It can be easily palpated so it is an option for midlines and EDC device insertion if the area of flexion at the antecubital fossa can be avoided.

The median antebrachial veins ascend anteriorly in the forearms to join the basilic vein or medial cubital veins (sometimes both). The medial antebrachial ascends from the wrist. These veins might appear suitable for cannulation but because they are usually situated between two branches of the median nerve, performing venepuncture at this site can be extremely painful. The basilic and cephalic veins then continue into the forearm.

The median cubital vein continues to run diagonally across the antecubital fossa connecting the basilic vein and the cephalic veins (Scales, 2005). There is a great variation in the pattern of veins in this area and sometimes, the median cubital vein is not always visible.

Antecubital fossa

Often prominent in the antecubital fossa, the median cubital vein is commonly used for venepuncture and cannulation. It has a small diameter and a variable course. It is not a vein recommended for midline or PICC insertion due to being in an area of flexion, which is known to potentially lead to mechanical phlebitis (Gorski, 2021).

Veins of the upper arm

Deep veins in the upper arm can be used for the insertion of midlines and PICCs and arm / PICC ports. These are:

• Cephalic vein
• Brachial vein
• Basilic vein

Image 3: Main veins of the arm

Cephalic vein

The cephalic vein extends from the radial side of the wrist and runs along the lateral part of the upper arm. It then travels along the pectoral-deltoid groove and joins the axillary vein. It is usually smaller than the basilic vein and may be tortuous as it ascends the upper arm. The accessory cephalic vein joins the cephalic vein at the lateral border of the arm. There is an added risk of stricture formation at the junction or the accessory cephalic and the main cephalic vein. This can make PICC insertion or arm port insertion challenging and so is a less desirable vein selection for these devices (Bodenham et al., 2016).

As midline catheters do not extend beyond the axillary line, the cephalic vein of the upper arm remains a suitable access vein for midline catheters. However, the diameter of the veins should be considered to ensure an adequate catheter to vein ratio (CVR) (Sharp, 2016).

Brachial vein

The brachial vein is a deep vein in the arm; this vessel is paired closely with the brachial artery and brachial nerves. It carries the greatest risk of damage to adjacent structures (nerve and artery) and, therefore, should only be accessed with ultrasound guidance to minimise the risk of nerve damage.

Basilic vein

The basilic vein begins along the ulnar side of the forearm. Along its course, other veins connect to it, including a branch from the cephalic vein (median cubital vein). This vein joins the basilic vein near the elbow. The basilic vein continues to travel up in a groove between the biceps brachii and pronator teres muscles. It continues to cross the brachial artery and runs up and along the edge of the biceps brachii. Below the level of the axilla, the basilic vein then travels deeper into the arm. Here it is joined by the deep brachial veins from the middle of the inner arm. Together, these veins become the axillary vein.

The optimal vein of choice for PICC and arm port insertion is the basilic vein because it is the largest of the three vessels and provides a straight and direct route to the Superior Vena Cava.

CONCLUSION

Vessel health and preservation (VHP) should always be considered when choosing a vein for device placement. The most appropriate vein and insertion site should be selected to best accommodate the device being placed. Both vein and insertion site should be selected with the patient and healthcare team and based on the projected treatment plan. You should always choose the most appropriate site that is likely to last the full length of prescribed therapy.

Although the practitioner should use their professional judgement to select the most appropriate vein for cannulation, this decision should be based on patient history and anatomy and the availability of ultrasound guidance and fluoroscopy.

References

Bodenham Chair A, Babu S, Bennett J, Binks R, Fee P, Fox B, Johnston AJ, Klein AA, Langton JA, Mclure H, Tighe SQ. Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016. Anaesthesia. 2016 May;71(5):573-85. doi: 10.1111/anae.13360. Epub 2016 Feb 17. Erratum in: Anaesthesia. 2016 Dec;71(12 ):1503. PMID: 26888253; PMCID: PMC5067617.

Fletcher S, Bodenham A. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000; 85:188–191.

Gorski, L. A. et al. (2021) ‘Infusion Therapy Standards of Practice, 8th Edition’, Journal of Infusion Nursing. doi: 10.1097/NAN.0000000000000396.

Harish K, Madhu YC. Inadvertent port: catheter placement in azygos vein. The International Journal of Angiology: Official Publication of the International College of Angiology, Inc. 2012 Jun;21(2):103-106. DOI: 10.1055/s-0032-1315628. PMID: 23730139; PMCID: PMC3444008.

Machat, S., Eisenhuber, E., Pfarl, G. et al. Complications of central venous port systems: a pictorial review. Insights Imaging 10, 86 (2019). https://doi.org/10.1186/s13244-019-0770-2

Scales K (2005) Vascular access: a guide to peripheral venous cannulation. Nursing Standard.  17-23;19(49):48-52. doi: 10.7748/ns2005.08.19.49.48.c3935. PMID: 16134420.

Sharp R, Cummings M, Fielder A, Mikocka-Walus A, Grech C, Esterman A. The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study. Int J Nurs Stud. 2015 Mar;52(3):677-85. doi: 10.1016/j.ijnurstu.2014.12.002. Epub 2014 Dec 19. PMID: 25593110.

Sun X, Xu J, Xia R, Wang C, Yu Z, Zhang J, Bai X, Jin Y. Efficacy and safety of ultrasound-guided totally implantable venous access ports via the right innominate vein in adult patients with cancer: Single-centre experience and protocol. Eur J Surg Oncol. 2019 Feb;45(2):275-278. doi: 10.1016/j.ejso.2018.07.048. Epub 2018 Jul 26. PMID: 30087070.

Tortora GJ. Derrickson, BH (2021).  Principles of Anatomy and Physiology, 16th Edition Available E-book: Principles of Anatomy and Physiology, 16th Edition | Wiley ISBN: 978-1-119-66268-6

Unal AE, Bayar S, Arat M, Ilhan O. Malpositioning of Hickman catheters, left versus right sided attempts. Transfus Apher Sci. 2003 Feb;28(1):9-12. doi: 10.1016/S1473-0502(02)00094-0. PMID: 12620263.