Is lymph node removal or breast cancer a contraindication for using an arm for venous access?

From the Guidelines

Using an arm on the same side as lymph node removal or breast cancer surgery for venous access is generally contraindicated due to the increased risk of lymphedema and other complications. Patients who have undergone axillary lymph node dissection or radiation therapy as part of breast cancer treatment should avoid venipuncture, blood pressure measurements, and IV placements in the affected arm whenever possible, as stated in the american cancer society/american society of clinical oncology breast cancer survivorship care guideline 1. This precaution is necessary because these procedures can damage the lymphatic system in the arm, which is already compromised by the surgery or radiation. The lymphatic system in the affected arm has reduced capacity to drain fluid and fight infection, making the arm more susceptible to lymphedema, a chronic and potentially serious condition characterized by swelling, discomfort, and increased infection risk.

Some key points to consider:

• The incidence of lymphedema among breast cancer survivors varies widely, but it is estimated that over 40% of survivors will experience lymphedema to some degree 1.
• The risk of lymphedema is much lower with sentinel lymph node dissections than with the full axillary lymph node dissection previously performed in all cases 1.
• Radiation treatment may cause or exacerbate lymphedema, especially radiation to the supraclavicular lymph nodes or axilla 1.
• The International Society of Lymphology provides a staging system to categorize the extent of lymphedema, and patients with lymphedema are also at greater risk for the development of cellulitis of the breast, arm, or chest 1.

In emergency situations where no other access is available, the affected arm may be used as a last resort, but this should be documented clearly and the IV removed as soon as an alternative site becomes available. Healthcare providers should always ask patients about breast cancer history and lymph node removal before selecting venous access sites to ensure patient safety and prevent complications, as recommended by the esmo clinical practice guidelines for diagnosis, treatment and follow-up of primary breast cancer 1.

The most recent and highest quality study, published in 2019, supports the idea that axillary lymph node dissection is associated with lymphedema affecting the upper limb in up to 25% of women following surgery, and that sentinel lymph node biopsy delivers less morbidity in terms of shoulder stiffness and arm swelling 1. Therefore, healthcare providers should prioritize alternative venous access sites and take precautions to minimize the risk of lymphedema and other complications in patients with a history of breast cancer or lymph node removal.

From the Research

Lymph Node Removal and Venous Access

• The use of the arm for venous access after lymph node removal for breast cancer is a topic of discussion, with some studies suggesting it may be safe under certain conditions 2.
• A study published in the Journal of Clinical Nursing found that the risk of complications after a needle puncture or intravenous injection in the ipsilateral arm of women who have undergone axillary lymph node clearance for breast cancer is low if current guidelines are followed 2.
• However, another study published in the British Journal of Nursing notes that lymphoedema may be triggered by any type of injection, and standard advice given to patients following axillary node removal is to avoid any injection or blood pressure measurement on the ipsilateral arm 3.

Risks and Benefits

• The risks and benefits of needle use in patients after axillary node surgery are not well-established, with some studies suggesting that the evidence base in this area is severely lacking 3.
• A small audit of guidelines found that out of 14 patients who underwent non-accidental skin puncture (NASP) procedures in the at-risk arm, no patients reported swelling to that limb within a month of these procedures 3.
• Another study published in Surgical Oncology notes that lymphedema is a relatively common, potentially serious and unpleasant complication after axillary lymph node dissection (ALND) for breast cancer, and that the risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy 4.

Protective Factors

• A study published in the Annals of Surgical Oncology found that immediate lymphatic reconstruction (ILR) and younger age are significantly associated with normal lymphatic function after ALND for treatment of breast cancer 5.
• The study suggests that undergoing ILR may be protective against developing breast cancer-related lymphedema, and that increased age is associated with decreased odds of normal lymphatic function 5.
• Another study published in The American Surgeon found that ALND with ILR does not decrease the number of drain days compared to ALND without ILR in patients with breast cancer, although the incidence of seromas was lower in the intervention arm 6.