For a patient with left‑sided breast cancer and left axillary lymph‑node involvement receiving neoadjuvant intravenous chemotherapy, which hand (arm) should be used for IV access?

IV Access Site Selection for Neoadjuvant Chemotherapy in Left-Sided Breast Cancer

Use the right arm (contralateral side) for IV chemotherapy access in this patient with left breast cancer and left axillary lymph node involvement. 1

Primary Recommendation

The contralateral (right) arm is the preferred site for IV access during neoadjuvant chemotherapy in patients with ipsilateral axillary lymph node involvement. 1 This recommendation prioritizes prevention of lymphedema and maintains optimal venous access throughout the treatment course.

Clinical Decision Algorithm

Step 1: Assess for Active Lymphedema

• If lymphedema is present in the left arm: The ipsilateral arm is contraindicated for IV access. 1
• If no lymphedema is present: The ipsilateral arm can technically be used, but the contralateral arm remains preferred. 1

Step 2: Evaluate Contralateral Arm Viability

• Examine the right arm for patent veins suitable for chemotherapy administration. 1
• Assess for any conditions that would preclude right arm use (superior vena cava syndrome, prior venous thrombosis, etc.). 1

Step 3: Consider Central Venous Access if Needed

• If peripheral access is inadequate bilaterally, central venous catheter placement should be considered. 2
• Central ports can be safely placed on either side, with no difference in complication rates between ipsilateral versus contralateral placement. 2

Evidence Supporting Contralateral Use

While recent evidence demonstrates that ipsilateral arm use does not significantly increase lymphedema risk in surgical patients 3, 4, the neoadjuvant chemotherapy setting presents unique considerations:

• Repeated venipuncture burden: Chemotherapy requires multiple IV accesses over weeks to months, representing cumulative trauma to the lymphatic system. 1
• Pre-existing lymph node involvement: This patient has documented left axillary lymph node disease, indicating already compromised lymphatic drainage. 1
• Prevention over intervention: Using the contralateral arm eliminates any theoretical risk while maintaining quality of life. 1

Important Clinical Caveats

When Ipsilateral Use May Be Acceptable

Research shows ipsilateral arm use for single IV placements carries minimal risk (3.9 per 10,000 complications). 3 However, this data primarily reflects surgical anesthesia cases, not repeated chemotherapy administration. 3

Avoid Unnecessary Restrictions

• Do not restrict ipsilateral arm use for blood pressure measurements or single blood draws without medical indication, as this causes patient anxiety without evidence-based benefit. 1, 4
• The blanket prohibition of any ipsilateral arm use is outdated and not supported by current evidence. 4

Central Venous Access Considerations

If peripheral access becomes problematic:

• Port placement on either side shows equivalent complication rates (7.3% ipsilateral vs 6.1% contralateral). 2
• Lymphedema rates are similar regardless of port side (20% ipsilateral vs 21.9% contralateral). 2
• The type of axillary surgery, not port location, determines lymphedema risk. 2

Practical Implementation

For this specific patient receiving first-cycle neoadjuvant chemotherapy:

• Establish IV access in the right arm for chemotherapy infusion. 1
• Document baseline arm measurements bilaterally to monitor for lymphedema development. 1
• Educate the patient that routine blood pressure and blood draws can use either arm, but chemotherapy infusions should preferentially use the right arm. 1, 4
• If right arm access fails after multiple attempts, consider central venous catheter placement rather than repeated ipsilateral attempts. 2