Cephalic Vein Management During Total Shoulder Arthroplasty
During total shoulder arthroplasty, the cephalic vein should be retracted laterally in most cases due to the greater number of lateral feeder vessels compared to medial branches in the deltopectoral groove.
Anatomical Considerations
- Anatomical studies have demonstrated that the cephalic vein in the deltopectoral groove has more lateral feeder vessels than medial branches, supporting lateral retraction of the vein during shoulder surgery 1
- The majority of these feeder vessels are located in the proximal half of the surgical incision, making careful dissection in this area particularly important 1
- The cephalic vein typically runs lateral to the deltopectoral groove before passing anterior to the clavicle, though anatomical variations exist 2
Surgical Approach Recommendations
- When using a deltopectoral approach for shoulder arthroplasty, lateral retraction of the cephalic vein is preferred to preserve the maximum number of feeder vessels 1
- Careful identification and preservation of the cephalic vein is important to prevent venous injury, which could lead to excessive bleeding and compromise visualization during the procedure 3
- Meticulous surgical dissection and careful retractor placement are essential to avoid injury to the cephalic vein, regardless of which direction it is retracted 3
Special Considerations
- In patients with previous axillary lymph node dissection, a deltopectoral approach with cephalic vein preservation can be utilized without substantial risk of worsening lymphedema or wound complications 4
- When creating anterior portals during shoulder procedures, surgeons should be aware that the cephalic vein travels approximately 23.4 mm distal to the coracoid tip, requiring careful portal placement to avoid vascular injury 5
- In patients with arteriovenous fistulas in the ipsilateral extremity, the cephalic vein may be arterialized with increased diameter and thickness, requiring additional precautions to prevent catastrophic bleeding 3
Risk Mitigation
- Ultrasound guidance is strongly recommended for central venous access procedures to reduce complications, and this principle can be applied to better visualize and protect the cephalic vein during shoulder approaches 6
- Preoperative cross-matching and expeditious vascular surgery availability should be considered in cases with high risk of vascular injury 3
- Surgeons performing fewer than two shoulder arthroplasties per year have higher complication rates, suggesting that experience with the procedure and familiarity with vascular anatomy are important factors in reducing complications 7
Conclusion
Based on anatomical evidence, lateral retraction of the cephalic vein is recommended during the deltopectoral approach for total shoulder arthroplasty to preserve the maximum number of feeder vessels. However, regardless of retraction direction, careful identification and protection of the vein are essential to prevent vascular complications.