Can a peripheral intravenous (IV) line be placed in the arm of a person with a double mastectomy?

Peripheral IV Placement in Patients with Double Mastectomy

Peripheral IV lines can be safely placed in the arm of a person with a double mastectomy, as there is no evidence that this practice increases the risk of complications.

Evidence and Rationale

The concern about avoiding IV placement in the arm ipsilateral to breast cancer surgery stems from historical fears about increasing the risk of breast cancer-related lymphedema (BCRL). However, recent evidence challenges this practice:

• A large retrospective study of 3,724 patients with 7,896 IV placements found no significant difference in complication rates between IVs placed in the ipsilateral arm versus the contralateral arm following breast cancer surgery 1. The study found:
  • Only 3.9 complications per 10,000 IV placements in the ipsilateral arm
  • No complications were observed in patients with IV placement ipsilateral to axillary node dissection

Guidelines for IV Placement in Post-Mastectomy Patients

The American Heart Association specifically addresses this issue in their guidelines for blood pressure measurement, stating: "In women who have had a mastectomy, blood pressure can be measured in both arms unless there is lymphedema" 2.

When placing an IV in a patient with double mastectomy:

1. Assess for lymphedema first:

   • If lymphedema is present in either arm, avoid that arm for IV placement
   • If no lymphedema is present, either arm can be used

2. Follow standard IV placement protocols:

   • Use upper extremity sites rather than lower extremity sites to prevent phlebitis 3
   • Select appropriate catheter size based on the vein diameter (minimum 2.0-2.5mm vein diameter is recommended) 2
   • Rotate venipuncture sites if repeated access is needed 2

3. Maintain proper catheter care:

   • Replace peripheral venous catheters every 72-96 hours 3
   • Evaluate the catheter insertion site daily for signs of phlebitis 3
   • Remove catheters immediately if signs of phlebitis develop (warmth, tenderness, erythema, palpable venous cord) 3

Special Considerations

• Vein preservation: In patients with chronic kidney disease who may need future vascular access for hemodialysis, consider preserving veins of the dorsum of the hand as preferred sites for IV cannulation 2

• Duration-based catheter selection: For longer-term therapy needs, consider:

  • Midline catheter for 6-14 days
  • PICC line for 15-30 days
  • Tunneled central venous catheter for ≥31 days 3

Conclusion

The practice of avoiding IV placement in the arm ipsilateral to breast cancer surgery is not supported by current evidence. The risk of complications is extremely low (3.9 per 10,000 IV placements) and not significantly different from placement in the contralateral arm 1. Therefore, either arm can be safely used for peripheral IV placement in patients with double mastectomy, provided there is no lymphedema present.