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Anatomy of a Procedure - Subclavian Cannulation

The subclavian vein (SCV) is an important site for central venous access. Cannulation of the SCV is associated with infectious and thrombotic complications to a lesser extent that the most common alternative sites (internal jugular vein [IJV] and femoral vein [FV]). Further, infraclavicular SCV access does not interfere with cervical immobilization in trauma patients and this location permits greater patient mobility after placement. However, access of the SCV is technically challenging due to the overlying clavicle and the proximity to the subclavian artery (SCA), phrenic nerve, brachial plexus, dome of the pleura/lung, and on the left side, the thoracic duct. The SCV is incompressible, rendering…

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 LANDMARK-guided Subclavian Central Line Insertion - a How-To Guide

A description of the technique I use for landmark-guided subclavian central line insertion, that in my opinion, is relatively simple and safe. This is a increasingly under-performed procedure, but one that has its uses and place.

 Microconvex Probe Subclavian Central Venous Catheterisation

Our preferred method of central venous access. The microconvex probe allows for real-time confirmation of correct guide-wire positioning.

 Shrug Technique for US-guided subclavian lines

The CDC guidelines recommend placing subclavian lines to reduce the risk of catheter-related bloodstream infections. Meanwhile, mounting evidence suggests that we should probably be placing lines with ultrasound guidance. Unfortunately, the ultrasound-guided subclavian can be tricky. This post describes a slight modification that could make the technique easier and safer.

 The subclavian vein may be the preferred location over IJ and Femoral Locations for Central Line Placement

Where to place a central venous catheter is a decision driven mainly by individual preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause pneumothorax, compared to other sites. Now, the 3SITES study was a prospective, randomized trial of 3471 central venous catheter insertions supervised by experienced operators that provides more information about insertion location. The primary outcome of the trial was a composite endpoint of either a catheter related bloodstream infection (CLABSI), or a deep venous thrombosis at the site. Importantly, ultrasound guidance was only used two-thirds of the time in internal jugular line placements (vs. 16% in subclavian line placements). Also, chlorhexidine antiseptic was used less than half the time (in favor of povidone-iodine) in these central line insertions.

 Ultrasound-Guided Subclavian Vein Cannulation: The Vessel to Remember

Ultrasound-guided subclavian vein access is a safe, effective and efficient option for central venous cannulation. Using ultrasound can decrease the time to cannulation in addition to many of the feared complications.

Articles of Interest

Advanced Critical Care Ultrasound: Subclavian Central Venous Access - Dealer's Choice

When deciding which of the three typical sites (internal jugular, femoral, and subclavian) to choose for central venous access, much can go into the site selection. Infection rates, risk of bleeding, risk to surrounding structures, incidence of deep venous thrombosis (DVT), and specific complications such as pneumothorax are all things to consider.

Blind Technique for Subclavian Central Line Placement

This case demonstrates a blind technique used for subclavian central line placement when imaging is not available. It was performed in Honduras on a surgical mission with the World Surgical Foundation in a resource-poor environment.

How I do it with ultrasound: subclavian central venous Catheter insertion.

Video by Scott J. Millington MD.

Infraclavicular Subclavian Placement

Placement of subclavian central venous catheter (central line, CVC).

Subclavian Venous Access

Ultrasound can be used to enhance venous access to the subclavian vein. While the ultrasound-based approach is not the default standard, it can still be a great asset in many cases where the anatomy and vasculature of the upper torso is non-standard and/or where the risk of pneumothorax may itself be a substantive risk to the patient.

Tips and Tricks: US-Guided Subclavian Vein

As the SCV courses under the clavicle, it has a short supraclavicular course before it merges with the internal jugular vein to form the brachiocephalic vein. The confluence of these two major veins provides a large venous space that is easy to access with the supraclavicular approach. Although the infraclavicular approach is more commonly taught and used, there has been some limited evidence to suggest that the ultrasound-guided supraclavicular in-plane approach to SCV cannulation may be more favorable than the infraclavicular approach.

Ultrasound Guided Subclavian Line Pearls

The CDC prefers a subclavian site as opposed to jugular vs femoral in adult patients to minimize infection risk. Also, the clinical scenario may preclude you from using the typical IJ or femoral sites (think trauma situations with c-spine immobilization, pelvic fractures, etc).

Ultrasound-guided left subclavian central venous catheterisation

In our opinion the easiest and most convenient way to set up a central line.