Breast cancer incidence continues to rise, with cases increasing by almost 20% in the UK since the 1990s, and breast cancer remaining one of the most common cancers requiring surgical intervention, including mastectomy and axillary lymph node surgery[1].
These procedures, while lifesaving, can disrupt lymphatic drainage pathways. When lymph nodes in the axilla are removed or irradiated, lymph fluid may no longer drain efficiently from the arm, increasing the risk of lymphoedema – an uncomfortable, sometimes debilitating swelling that can appear months or even years after treatment[2].
Vascular access decision making in these patients remains a complex and often contentious area of practice. The available evidence base is limited, with few high-quality studies clearly quantifying the true risk of lymphoedema associated with venepuncture or vascular access devices in this population. In the absence of definitive data, clinical practice has gradually shifted towards absolute rules, most commonly the instruction to “never use that arm”, driven by a well-founded fear of causing irreversible harm.
As a result, vascular access teams are frequently asked to assess and accept risk that they do not own, often in time pressured or clinically challenging situations, while patients may carry lifelong messaging that no longer reflects contemporary surgical techniques or individual risk. Recognising this uncertainty, the Association of Anaesthetists emphasises a pragmatic, patient centred approach to safe vascular access, recommending individualised risk assessment, shared decision making, and avoidance of blanket rules based solely on laterality3. Modern vascular access guidelines also now highlight this patient group as requiring specific, thoughtful management[3].
Avoiding Vascular Access in the Affected Limb
Conventional teaching has long advised clinicians to avoid venepuncture, blood pressure cuffs and vascular access on the arm affected by lymph node removal[4]. This caution is rooted in the understanding that trauma or infection in the compromised limb can further elevate lymphoedema risk, prompting many teams to prohibit cannulation or catheter insertion in the affected arm altogether.
In practice, however, challenges arise:
- Emergency access needs may force the use of the affected limb when alternatives are limited.
- Swelling, scarring and altered anatomy complicate site selection and device insertion2.
- Lack of consistent guidelines leads to varied practice between institutions, creating confusion for clinicians and anxiety for patients.
- When both arms are affected, clinicians may feel unsure which site presents the lowest risk.
This variability underscores the need for clear approaches based on clinical evidence to ensure safe and functional vascular access in this population.
Prioritising Vessel-Health Preservation
The Association of Anaesthetists safe vascular access guidelines (2025) promote a holistic, patient‑centred strategy that prioritises vessel‑health preservation, especially for patients post‑mastectomy or axillary lymph node surgery3.
Guidelines and related literature support the following principles:
- Avoid the affected arm where possible, but recognise that in emergencies, its use may be justified4.
- Use ultrasound guidance to enhance safety and reduce complications.
- Select devices located away from the axillary lymphatic basin, such as internal jugular (IJ) or femoral central venous access.
- Document and communicate clearly when deviations from standard practice are necessary.
The Association of Anaesthetists guidelines reinforce that relying exclusively on upper‑arm access may not always be appropriate in this patient group, and that alternative central access strategies should be considered, for example, via non‑limb sites.
What is the Best Vascular Access Device for Mastectomy and Lymphoedema‑Risk Patients?
The available literature suggests that placing PICCs and midlines in an affected arm may increase theoretical risk and should be avoided where reasonable alternatives exist, particularly in patients with existing or high‑risk lymphoedema. This is due to elevated risk of provoking or worsening lymphoedema. This could have the effect of delaying care where policies enforce absolute avoidance of access via the affected limb[5].
Where upper‑limb access is felt to confer unacceptable risk, alternative device strategies may be required:
✅ Small‑Bore Internal Jugular (IJ) Central Venous Catheters (CVCs)
The internal jugular vein is a central venous site located in the neck, entirely separate from the upper limb lymphatic drainage system. Access here therefore avoids direct trauma to the arm or axilla, which is crucial in patients at risk of lymphoedema after mastectomy or axillary lymph node surgery. Clinical procedural guidelines identify the internal jugular route as a preferred site for central venous access because it offers lower complication and infection risk compared with subclavian or femoral approaches, making it a safe option when upper‑limb vascular access should be avoided[6].
✅ Small‑Bore Femoral CVCs (Alternative)
NIVAS clinical standards and aligned national guidance describe femoral venous access as a higher‑risk site for catheter‑related infection[7] and recommend its avoidance where reasonable alternatives exist, particularly outside emergency settings[8]. However, when internal jugular access is not possible, femoral catheterisation is an accepted alternative central venous route, as it provides reliable access without involving the upper limb or axillary region. This makes it a safe, limb‑sparing option for patients at risk of lymphoedema following mastectomy or axillary surgery. Clinical guidance confirms that femoral access is a standard central line site used when IJ access is contraindicated or impractical[9].
✅ Ports and PICC-Ports
After consideration of the limb‑sparing access strategies outlined above, there may be circumstances in which vascular access in the ipsilateral arm is contemplated. Historically, recommendations advised avoidance of vascular access in the affected limb for a defined period, often cited as three years following mastectomy or axillary surgery, reflecting earlier surgical techniques associated with more extensive lymphatic disruption.
Contemporary breast cancer surgery is frequently less radical, with improved lymph‑preserving approaches and more refined risk stratification. In parallel, advances in device design and insertion technique have expanded access options. As a result, totally implanted venous access ports or PICC‑ports are now more commonly considered in selected patients where alternative routes are unsuitable, particularly for longer‑term therapies. Such decisions should be individualised, incorporate patient discussion, and balance the theoretical risk of lymphoedema against the clinical need for durable, reliable venous access.
Benefits and Challenges of Avoiding the Compromised Upper Limb
Benefits
- Reduced lymphoedema risk, due to avoidance of the compromised upper limb.
- Higher reliability and safety, particularly with ultrasound‑guided IJ access3.
- Greater consistency in clinical practice, supported by national guidance and clearer procedural recommendations.
- Enhanced patient confidence, as access strategies minimise trauma to previously operated tissue.
Challenges
- Training requirements for consistent, confident ultrasound‑guided IJ or femoral access3.
- Service resource demands, including access to vascular access specialists.
- Shifting longstanding beliefs, some clinicians and patients may be unsure about intervention on the affected side, despite the evolving evidence.
- Patient communication, many patients may have previously been told “never use that arm”, meaning that where access is required in ‘that arm’ they will require suitable reassurance and education.
Conclusion
As breast cancer survival continues to improve, clinicians will increasingly encounter patients with a history of mastectomy or axillary lymph node surgery who require vascular access for unrelated care. While lymphoedema remains a serious and life‑altering complication, the evidence guiding vascular access decision making in this population is limited and evolving. Absolute rules based solely on laterality may oversimplify a complex risk profile that is influenced by surgical technique, adjuvant therapy, elapsed time, clinical urgency, and individual patient factors.
Rather than offering a single, definitive solution, current guidance supports a pragmatic and patient‑centred approach. Avoidance of the affected limb may be appropriate in higher‑risk situations or where suitable alternatives exist, but this must be balanced against procedural risk, access requirements, and the potential consequences of delayed or suboptimal therapy. Non‑arm central access, such as ultrasound‑guided internal jugular or femoral routes, may have a role in selected cases, but should be considered within a broader framework of shared decision making and documented clinical reasoning.
Ultimately, the challenge is not to eliminate risk entirely, but to acknowledge uncertainty, avoid blanket prohibitions, and support informed, individualised vascular access decisions that prioritise both patient safety and clinical effectiveness.
References
[1] Sherwin A, Buggy DJ. Anaesthesia for breast surgery. BJA Education. 2018;18(11):342 348. Available from: https://www.bjaed.org/article/S2058-5349(18)30101-X/fulltext [campusvygon.com]
[2] Susan G. Komen Foundation. Lymphedema Related to Breast Cancer. 2026. Available from: https://www.komen.org/breast-cancer/survivorship/health-concerns/lymphedema/
[3] Association of Anaesthetists. Guidelines: safe vascular access 2025. 2025. Available from: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/anae.16727
[4] Royal College of Anaesthetists. Information for patients at risk of lymphoedema undergoing anaesthesia and surgery. 2018. Available from: https://www.rcoa.ac.uk/sites/default/files/documents/2019-11/Factsheet-Lymphoedemaweb_0.pdf
[5] Hadjistyllis et al. Which Arm – Vascular Access Procedures and Breast Surgery. IVTEAM. 2024.
Available from: https://www.ivteam.com/intravenous-literature/vascular-access/which-arm-vascular-access-procedures-and-breast-surgery/
[6] Berry C, Spain DA. How to Do Internal Jugular Vein Cannulation. Merck Manual Professional Edition. Updated Oct 2024; Modified Apr 2025. Available from: https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-central-vascular-procedures/how-to-do-internal-jugular-vein-cannulation
[7] Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. Epic4: national evidence‑based guidelines for preventing healthcare‑associated infections in NHS hospitals in England. J Hosp Infect. 2014;86(Suppl 1):S1–70.
[8] Barton A; National Infusion and Vascular Access Society (NIVAS). NIVAS clinical standards for vascular access and intravenous infusion therapy. London: NIVAS; 2025.
[9] Miers J, Mackenzie J. Procedure: Central Venous Catheter (IJV). Life in the Fast Lane (LITFL). 2025 Sep 18. Available from: https://litfl.com/procedure-central-venous-catheter-ijv/
