Placement of Subclavian Venous Catheters

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Official reprint from UpToDate

www.uptodate.com2015 UpToDate

Authors

Alan C Heffner, MD

Mark P Androes, MD

Section Editors

Allan B Wolfson, MD

John F Eidt, MDJoseph L Mills, Sr, MD

Deputy Editor

Kathryn A Collins, MD, PhD,

FACS

Placement of subclavian venous catheters

All topics are updated as new evidence becomes available and our peer review processis complete.

Literature review current through: May 2015. | This topic last updated: Jan 20, 2015.

INTRODUCTION Central catheters provide dependable intravenous access and enable hemodynamic

monitoring and blood sampling [1-3]. The subclavian veins are a common site for temporary central venous

access, including tunneled catheters and subcutaneous ports for chemotherapy, prolonged antibiotic

therapy, and parenteral nutrition.

Subclavian venous cannulation and catheter placement will be reviewed here. General considerations,

complications of venous access, and issues related to other access sites are discussed elsewhere. (See"Overview of central venous access"and "Complications of central venous catheters and their prevention"

and "Placement of jugular venous catheters"and "Placement of femoral venous catheters".)

INDICATIONS The subclavian veins are reliable access points for temporary and permanent (eg,

tunneled central catheters and subcutaneous ports) venous cannulation to support hemodynamic

monitoring, fluid and medication administration, and parenteral nutrition (table 1). The left subclavian access

is particularly well suited for cardiac access, including placement of pulmonary artery catheters, transvenous

pacer leads, and implantable defibrillators.

Subclavian venous access may be preferred for subcutaneous port placement due to the short distance

between the subclavian vein and chest wall, making the catheter less prone to kinking.

Contraindications Relative contraindications to subclavian venous catheterization include coagulopathy

and altered local anatomy [4-8]. (See "Overview of central venous access", section on 'Contraindications'.)

Subclavian access should be avoided, if possible, at sites with altered local anatomy (eg, previous clavicle

fracture), prior access, or the presence of an indwelling pacemaker or internal defibrillator because these are

associated with a higher risk of failure, complication, and malposition [9,10].

In patients with significant unilateral lung disease, cannulation of the vessel ipsilateral to the compromised

lung is preferred to avoid decompensation in the event of a procedure-related pneumothorax.

The subclavian site should be avoided for large bore hemodialysis catheters due to the risk of venous

stenosis that limits outflow for future arteriovenous hemodialysis access [11,12]. (See "Overview of central

catheters for acute and chronic hemodialysis access", section on 'Access site considerations'.)

The subclavian access site is not appropriate for the short, relatively stiff catheters used for acute

hemodialysis or pheresis. These catheters do not have the flexibility needed to negotiate the curve from the

brachiocephalic vein into the superior vena cava. Perforation of the central veins can occur. (See

"Complications of central venous catheters and their prevention".)

Coagulopathy is a relative contraindication to central cannulation. However, there is little quality evidence to

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support this preference [4]. Although significant bleeding is uncommon, the subclavian approach is generally

avoided in patients with significant coagulopathy, including therapeutic anticoagulation, if an alternative

access point is available. Bleeding from the subclavian vein or inadvertent subclavian artery puncture may

go unrecognized and cannot be treated with direct pressure due to the deep location of these vessels

beneath the clavicle.

SUBCLAVIAN VEIN ANATOMY The clavicle is the primary surface landmark for subclavian cannulation

(picture 1). Moving laterally from the suprasternal notch, the bulky sternal head takes an elongated S-shape(a double curve in the horizontal plane); the medial two-thirds are convex anteriorly, and the lateral third is

concave anteriorly. The anterior convexity at the junction of the medial and middle thirds is known as the

"bend" or "break" in the clavicle, and serves as an important palpable landmark. (See 'Subclavian vein

cannulation'below.)

The subclavian vein is the direct continuation of the axillary vein beginning at the lateral border of the first rib

(figure 1and picture 1). The vein arches cephalad behind the medial clavicle and then slopes caudally to join

the internal jugular vein to form the brachiocephalic (innominate) vein posterior to the sternoclavicular joint.

The vein is accompanied by the subclavian artery located superior and posterior to the vein, and separated

from the vein by the anterior scalene muscle.

The neck is a complex area with multiple structures traversing the thoracic outlet. Injury is avoided by

knowing the location of these structures relative to the subclavian cannulation sites.

SUBCLAVIAN SITE SELECTION Right-handed operators often prefer right-sided subclavian access

procedures. Right subclavian anatomy carries the theoretical advantage of lower risk of complications due to

the lower pleural apex and absence of the thoracic duct. However, right-sided subclavian access is

associated with higher rates of catheter malposition and vessel trauma compared with left-sided access [13].

A left-sided access may be preferred when immediate cardiac access is needed (eg, temporary transvenous

pacer placement, pulmonary artery catheter) since the guidewire and catheter are more easily directed into

the superior vena cava and right heart.

We access ipsilateral to the compromised lung in patients with significant unilateral lung disease to avoid

respiratory compromise in the event of a pneumothorax. (See 'Contraindications'above.)

In patients with prior catheter placement in the subclavian or internal jugular veins, or a history of upper

extremity deep venous thrombosis, consider ultrasound to assess venous patency prior to attempting

subclavian access. (See "Catheter-related upper extremity venous thrombosis", section on 'Duplex

ultrasonography'.)

GENERAL PREPARATION General considerations for patient preparation, including catheter and access

site selection, monitoring and sedation, measures to control infection, and consent, are discussed

elsewhere. (See "Overview of central venous access", section on 'Preparation'.)

The lung lies deep and inferior to the medial portion of the subclavian vein. The dome of the left lung

often extends above the level of the first rib on the left, but rarely on the right.

!

The phrenic nerve passes inferiorly along the anterior aspect of the anterior scalene muscle and

posterior to the origin of the brachiocephalic vein.

!

The brachial plexus is superior and deep to the medial portion of the subclavian artery.!

The left-sided thoracic duct and right-sided lymphatic duct course posterior to the subclavian vein and

enter the vessel near the confluence of the left subclavian vein with the left internal jugular vein.

!


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Equipment Subclavian venous catheters and other subclavian venous devices are usually placed using a

modified Seldinger technique in a series of defined steps usually using a kit that contains all the materials

needed for their placement. Typical supplies are given in the table (table 2) [14]. For non-tunneled catheters,

the steps for central venous catheterization are given in the table ( table 3). For tunneled catheters and other

devices, the steps are similar except that a sheath is placed over the guidewire and the catheter (or other

device such as pacemaker leads, filter) is placed through the sheath, which is then removed.

Prior to the placement of subclavian venous catheters, assemble the following equipment:

The proper functioning of any fluoroscopic equipment that will be used should be verified. Fluoroscopy is

rarely needed for subclavian access, but is routine when placing implanted catheters or devices (eg,

pacemaker, defibrillator, pulmonary artery catheter, vena cava filter) to measure the length of the catheter

needed and to image the sheath or device as it is introduced into the vein.

Skin preparation For subclavian venous access, a wide skin preparation that includes the neck and

chest above the nipple line allows the operator to attempt cannulation at an alternative ipsilateral target (eg,

jugular), if the initial plan fails. If difficult access is anticipated, the neck and chest can be prepared

bilaterally.

Positioning For subclavian venous access, the clinician should position the patients bed or procedure

table at a comfortable height. The position of the operator depends upon the vein cannulation technique

chosen. We prefer to stand at the patients shoulder for infraclavicular access. Standing at the head of the

bed is an alternative for the supraclavicular technique. (See 'Approaches to the subclavian vein'below.)

Unlike the jugular vein, Trendelenburg positioning does not significantly affect subclavian diameter, but

Trendelenburg positioning may help prevent air embolus [15-18]. Most patients can be safely positioned

supine or in Trendelenburg position. However, critically ill and obese patients may develop respiratory

compromise and close monitoring is required. Successful supraclavicular subclavian cannulation has been

performed in upright and prone positions under extenuating circumstances [19]. Some patients may require

anesthesia with a controlled airway for safe placement of central venous catheters and devices. (See"Anesthesia for the obese patient", section on 'Patient positioning'.)

Various anatomic studies have shown that the relationship between the subclavian vein and clavicle change

with head, arm, and shoulder positioning [15,16,20-22].

Shoulder elevation shifts the point of intersection of the vein with the clavicle more medially, and the length

of overlap is reduced. Thus, to facilitate subclavian cannulation, we place the patients arms at their sides

Ultrasound machine (see "Principles of ultrasound-guided venous access", section on 'Ultrasound

machine preparation').

!

Sterile ultrasound transducer gel!

Central line kit with intravenous catheter (size and length based upon diameter and depth of vein)!

Sterile drapes, gloves, gown, surgical mask, and cap!

Topical antiseptic (eg, chlorhexidine, povidone iodine) (see "Adjunctive measures for prevention of

surgical site infection in adults", section on 'Skin antisepsis')

!

Local anesthetic (see "Topical anesthetics in children"and "Infiltration of local anesthetics").!

Isotonic saline and/or heparin for flushing the catheter!

Transparent adhesive dressing, tape!

Intravenous tubing and connectors (eg, needleless Luer connector, three-way stopcock)!


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(adducted) and use a neutral to lower shoulder positioning, which increases the area of contact between the

subclavian vein and the undersurface of the clavicle providing a consistent landmark. A shoulder position 5

cm below neutral shoulder position appears to provide maximal amount of overlap [21]. The natural

tendency for the shoulders to assume a cephalad orientation with Trendelenburg position can be countered

by gentle caudal traction on the arm performed by a bedside assistant. One small clinical trial demonstrated

improved cannulation using caudal arm traction [21].

Recommendations to turn the head toward the side of the cannulation are based on anatomic studies andreduced catheter malposition in a single pediatric study, but such positioning has had no effect in trials on

adult patients [23-25].

Special considerations for positioning patients for infraclavicular versus supraclavicular access include:

SUBCLAVIAN VEIN CANNULATION The subclavian vein is generally cannulated using one of three

anatomic approaches with a large bore access needle using landmark techniques. Following cannulation,

subclavian catheters are placed using an orderly sequence of steps (table 3).

Needle access Although ultrasound-guided subclavian venous access has been described, no significant

benefit as yet has been identified for this access site, and thus, landmark techniques are used for needle

placement. (See 'Dynamic ultrasound guidance for subclavian access'below.)

General techniques Although less commonly used compared with internal jugular vein cannulation, a

seeker needle may, at times, be useful. Angiocatheters (catheter over a needle) are less commonly used to

access the subclavian vein. The general technique for each of these is described below. Isolated arterial

needle puncture is one of the most common complications of venous access, but is typically uneventful if

recognized prior to vessel dilation [28]. Confirmation that the access needle is in the vein is essential prior to

dilating the subcutaneous tissue and vein. (See 'Venous confirmation'below.)

There is a learning curve for central venous access procedures [29]. Experienced operators enjoy greater

success rates with fewer complications. Among both experienced and inexperienced operators, complication

rates increase with the number of introducer needle passes, and are significantly higher after two

unsuccessful passes [2,10,30]. If two attempts have been made, the needle should be completely removed

and the surface landmarks reassessed, a new access site chosen, or assistance from a more experienced

clinician obtained [2,9,26].

Access with introducer needle To access the subclavian vein with the 18 gauge introducer

needle:

For infraclavicular subclavian access (figure 2and picture 1), a small sandbag or rolled towel can be

placed between the scapulae to retract the shoulders and facilitate needle insertion by reducing the

deltoid prominence [26]. The maneuver also positions the vein closer to the clavicle for a more

consistent landmark [16,20]. Avoid excessive retraction because this reduces the anterior-posterior

dimension of the vein, flattening it [23].

!

For supraclavicular subclavian access (figure 3A-B), the lateral border of the clavicular head of thesternocleidomastoid muscle is the point of venous access. Contralateral rotation of the head away from

the site of access provides unobstructed access [27].

!

Insert the introducer needle into the skin and apply continuous negative pressure by pulling back on

the plunger of the syringe. Vein penetration will not be recognized unless negative pressure is applied,

but only a small amount of continuous negative pressure is needed (about 1 cc of a 10 cc syringe)

!


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Using a seeker needle Although more commonly used for internal jugular vein localization, a

small caliber (21 to 22 gauge) exploratory seeker (or finder) needle, 3.5 cm in length, may help locate the

subclavian vein (picture 2) [9,32,33]. This technique minimizes injury in the event of inadvertent arterial

puncture. However, with the infraclavicular approach to the subclavian vein, the seeker needle may not be

long enough to reach the vessel in some patients.

To use a seeker needle to aid introducer needle placement:

Using an angiocatheter An angiocatheter consists of an 18 gauge plastic catheter mounted on a

20 gauge needle. It is not commonly used for infraclavicular subclavian vein access and may not be long

enough to reach the vessel in some patients. However, the angiocatheter is a useful adjunct for the

supraclavicular approach. The technique for using an angiocatheter to access the internal jugular or femoral

vein is described separately. (See "Placement of jugular venous catheters", section on 'Using an

angiocatheter'and "Placement of femoral venous catheters", section on 'Using an angiocatheter' .)

Approaches to the subclavian vein The subclavian vein can be approached from above or below

the clavicle. The landmarks and needle placement for each of these approaches are presented below.

Infraclavicular approach Three insertion points are described for the infraclavicular approach to

the subclavian vein. The midpoint approach is the most commonly used technique [ 3,20].

during advancement of the needle.

Always advance and withdraw the needle in the same vector. Lateral movement of an inserted needle

can lacerate vessels and should notbe done. Prior to any redirection of the needle, it should be

withdrawn to the skin surface.

!

Anticipate that venous backflow into the introducer needle will be sudden, and steady the position of

your hand to avoid dislodgement from the vein when this occurs.

!

Failure to aspirate blood during needle advancement is common. In this circumstance, withdraw the

needle slowly while maintaining continuous negative pressure. Venous puncture may only be

recognized during needle withdrawal as the compliant vein may not be punctured during initial needle

advancement in up to one-third of cases [31]. Once access is achieved, stabilize the hub of the needle

and carefully remove the syringe to avoid dislodging the introducer needle from the vessel.

!

Cover the hub of the needle between manipulations and coordinate hub exposure with the patients

exhalation to avoid air entry during the subclavian access. Encourage the patient to hum or perform

Valsalva maneuvers to augment central venous pressure.

!

As described above for large-bore needle access, insert the seeker needle while applying negative

suction on the plunger of the syringe; more suction will be required (about 2 to 3 cc of a 10 cc syringe).

Steady, unimpeded blood return confirms intraluminal venous placement.

!

Once the needle enters the vein, withdraw the seeker needle, noting the angle and depth needed to

reach the vein. Alternatively, remove the syringe leaving the seeker needle in place to anchor thevessel and provide a guide for venous access by the introducer needle. While applying negative

pressure to the syringe, advance the introducer needle in the same vector, or alongside the preceding

seeker needle, into the vein.

!

For the midpoint approach, the needle is inserted 2 to 3 cm inferior to the midpoint of the clavicle

(approximately 1 to 2 cm lateral to the bend of the clavicle) and directed just posterior to the

!


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After the needle has penetrated the skin, the clavicle may be initially contacted. Take care not to push the

needle into the periosteum, as bone plug can occlude the lumen of the needle. The needle should be gently

walked deeper to reach the underside of the clavicle. The needle should remain parallel to the clavicle (in

the coronal plane) to allow it to pass cleanly beneath the bone and minimize the risk of pleural puncture. As

the needle passes beneath the junction of the middle and medial thirds of clavicle, it should enter the vein. If

the first needle pass is unsuccessful, orient the needle more cephalad on subsequent attempts.

An observational study at a large trauma center evaluated the most common errors during the placement of

infraclavicular subclavian venous access [35]. The most frequently observed errors during videotapedassessment of venous cannulation in 86 patients included improper or inadequate identification of anatomic

landmarks, improper needle insertion site, too shallow a needle trajectory, and insertion of the needle

through the periosteum of the clavicle.

Supraclavicular approach The supraclavicular approach aims to puncture the subclavian vein

near its junction with the internal jugular vein. The insertion of the clavicular head of the sternocleidomastoid

is the access landmark for this approach (figure 3Aand figure 3B).

The subclavian vein is 1 to 1.5 cm deep to the skin and easily reached using a seeker needle [ 36]. The

needle should be inserted 1 cm posterior to the sternocleidomastoid and 1 cm cephalad to the clavicle. The

needle is depressed 10 to 15 degrees below the coronal plane and oriented to bisect the angle between the

clavicle and the sternocleidomastoid (picture 4). The needle is advanced toward the venous confluencebehind the medial clavicle along a trajectory aimed just inferior to the contralateral nipple.

Axillary approach This approach is an uncommonly used technique accessing the vessel at the

junction of the subclavian and axillary veins via an ultrasound-guided infraclavicular approach.

Dynamic ultrasound guidance for subclavian access Although commonly used and recommended

for internal jugular and femoral venous access sites, real-time ultrasound guidance for both infra- and

supraclavicular approaches to the subclavian vein are described [31,37,38]. Technical complexity in

visualizing the vein due to acoustic shadowing from the overlying clavicle and rib is recognized, but one

small trial demonstrated improved infraclavicular cannulation and reduced mechanical complications using

ultrasound guidance compared with anatomic landmarks [37]. The principles of ultrasound in guiding venous

access are discussed in detail elsewhere. (See "Principles of ultrasound-guided venous access", section on

'Subclavian vein'.)

Venous confirmation An intraluminal position of the needle can be confirmed by observation of the

needle entering the vein with ultrasound-guided access coupled with a steady flow of dark blood into the

syringe. Bright red and high-pressure pulsatile bleeding are important but imperfect clues to arterial puncture

[39], which can occur, although less frequently, with ultrasound-guided access. Moreover, the absence of

these signs is not perfectly reliable for excluding inadvertent arterial puncture. Dark, nonpulsatile backflow of

suprasternal notch (figure 2and picture 3).

A lateral needle insertion (lateral to the midclavicular line) takes advantage of the thin anterior

convexity of the clavicle to facilitate a level coronal approach, which may improve safety if the vessel

can be reached by the cannulating needle [20,21,34].

!

The medial insertion point is along the inner third of the clavicle. The needle is directed cephalad

toward the suprasternal notch to penetrate the vessel at the broad confluence of the great veins. The

downside of this method is that medial positioning requires a steep approach beneath the thick medial

clavicle and passage through intervening soft tissue including the costoclavicular ligament.

!


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blood may be seen with arterial puncture in the face of oxygen desaturation, hypotension, or needle

malposition. If there is any doubt, the needles location can be confirmed by pressure transduction. As an

alternative, a blood gas can be drawn from the accessed venous site and compared with an arterial sample;

however, blood gas analysis is more time consuming.

To transduce the blood pressure:

Steady, unimpeded blood return confirms intraluminal placement. The hub of the needle should be

stabilized, and the syringe carefully removed to avoid dislodgement from the vessel. The needle hub should

be covered between manipulations to avoid the entry of air. The patients can be encouraged to hum or

perform Valsalva maneuvers to augment central venous pressure, and hub exposure can be coordinated

with spontaneous exhalation to avoid aspiration of air.

If the subclavian artery is inadvertently punctured, the needle can be withdrawn and pressure applied over

the site for 5 to 10 minutes. Elevating the ipsilateral arm overhead may help to compress the vein. If

subclavian artery catheterization is confirmed, the catheter should be left in place and vascular consultation

obtained.

CATHETER PLACEMENT Most catheters and other central venous devices are placed using the

Seldinger method, which refers to the use of a guidewire placed into a vessel to provide a conduit for

intravascular device placement [14]. Seldinger first described the guidewire technique for arterial cannulation

in 1953 and it was subsequently adopted for venous access procedures [14].

Guidewire handling Once the subclavian vein has been successfully accessed, a guidewire should be

advanced through the needle or angiocatheter. Multiple types of wires are available to assist with venous

access procedures. The most commonly used wire for initial subclavian venous access is a flexible J-tip

guidewire, favored because it negotiates curvatures and minimizes vessel trauma during passage (picture

5).

The subclavian approach (particularly from the right side) has the highest rate of catheter malposition

compared with other access sites (jugular, femoral), which is due to errant positioning of the guidewire [1].

Head position alters the relationship of the subclavian vein and may affect guidewire placement. (See

'Positioning'above.)

The J-tip guidewire passage is influenced by the needle bevel and J-tip orientation. Orienting of the needle

bevel caudally for infraclavicular access and medially for supraclavicular access facilitates guidewire

passage from the subclavian vein into the superior vena cava [27]. Similarly, passage of guidewire with the

J-tip directed caudally improves correct placement [40].

Complaints of facial pain following guidewire placement often indicate passage into the internal jugular vein.

Manual occlusion of the ipsilateral jugular vein during guidewire placement may decrease malposition into it

Attach the needle directly to the pressure tubing system!

Alternatively, replace the needle over a guidewire with an appropriate length angiocatheter or 18-gauge

single-lumen transduction catheter (without any intervening dilation). Connect the transduction catheter

to a pressure line and transducer and evaluate the pressure and waveform tracings on the monitor.

Typical venous waveforms should be seen (figure 4).

!

If a pressure transduction system is not available, attach a short length of saline-filled intravenous

tubing to the needle and extended it vertically to measure the pressure, which should approximate

anticipated venous pressure and demonstrate respiratory variation.

!


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[41].

The guidewire should always pass smoothly and easily thorough the needle, dilator, or catheter without

resistance. Methods to address resistance to guidewire advancement or withdrawal are discussed below.

To place the guidewire:

Tract dilation Central venous catheters are substantially larger caliber than the needle and guidewire

used for venous access. Dilation of the subcutaneous tissue tract is required for catheter insertion and is

accomplished by threading a single stiff tapered dilator or series of dilators over the wire to expand the

subcutaneous tissue and vein. The skin and fascia catheter tract should be dilated carefully with gentle

pressure. Only the soft tissue and vein wall need to be dilated. Overzealous efforts and guidewire kinking

(especially with stiff dilators) risk traumatic vein injury.

Many indwelling tunneled subclavian catheters are placed through a peel-away sheath. To place these

devices, a dilator-sheath combination is placed over the wire after the tract has been dilated. The dilator is

removed, and the catheter is placed through the sheath. Once the catheter is in place, the sheath is peeled

away from the catheter and discarded.

The dilator-sheath combination for large-bore tunneled catheters is stiff, and placement is facilitated with

fluoroscopy, which allows imaging of the tip of the dilator and sheath, ensuring that it is placed no further into

Position the tapered plastic introducer to straighten the distal J-tip (picture 6). The orientation of the

introducer needle bevel tip and the J-tip of the guidewire can help facilitate the direction of wirepassage.

!

Maintain the residual length of guidewire (50 cm standard length) under constant manual control to

maintain sterility and avoid its loss off the operating field.

!

Advance the guidewire only as far as needed to allow passage of the catheter over the wire.

Guidewires (and catheters) rarely require positioning more than 20 cm deep [5,42]. The atriocaval

junction averages 18 cm for right subclavian access, and 21 cm from the left subclavian [42]. These

average values vary depending upon stature. In an Asian study, average distances were slightly

shorter at 14 cm for the right subclavian vein and 17 cm for the left subclavian vein [ 43]. Advancing the

guidewire deeper risks intracardiac or inferior vena cava (IVC) wire placement with the potential for

cardiac arrhythmia, perforation, and snaring of other intravascular devices [44].

!

Never forcefully advance the guidewire, as this can kink and permanently deform the wire and risk

vessel injury. The guidewire should always pass smoothly and easily thorough the needle, dilator, or

catheter without resistance. Resistance to guidewire passage can be due to needle dislodgement,

compression of the guidewire against the vessel wall, or anatomic obstruction. Rotating the needle

and/or guidewire to reorient the bevel or J-tip may relieve impingement of the guidewire on the

posterior vessel wall.

!

If resistance persists, remove the guidewire and aspirate blood to confirm intraluminal needle position.

Reducing the angle of the needle against the skin may facilitate guidewire passage. Once the

guidewire is positioned, hold it firmly in place, and remove the needle.

!

Resistance during guidewire withdrawal can be managed by simultaneous removal of the needle and

indwelling wire. Continued resistance may indicate entrapment and warrants diagnostic radiography to

evaluate the wire appearance and position [45]. Withdrawing a kinked guidewire through the needle

can shear off the wire, allowing it to embolize [46].

!


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the vein than is necessary. (See 'Equipment'above.)

To place the dilator:

Positioning the catheter After the subcutaneous tissues and vein have been dilated, the catheter is

placed over the wire and positioned (picture 8).

To place and position the catheter:

Ideal insertion distance varies by patient size and anatomic site. To minimize intracardiac placement, do not

insert catheters more than 20 cm from any upper body access site [ 5,42]. Initial insertion depth for most

adults should be 16 cm for right-sided subclavian catheters and 20 cm for left-sided subclavian vein

catheters [9]. Height-based formulas to determine insertion depth exist, but there are no well-controlled

studies supporting their use [48,49]. Rare case reports implicate intracardiac catheter tip placement as a

possible cause of cardiac tamponade [50,51].

Once the guidewire is in place, making a controlled 3 mm stab incision (#11 blade) in the skin at the

guidewire entry site will prevent the dilator from catching.

!

Thread the stiff tapered dilator over the wire, making certain the guidewire does not advance, and is

not pulled out at the skin exit site. The guidewire and dilator should neverbe advanced as a singleunit, to avoid venous injury. The wire should serve as an immobile monorail over which the dilator (or

catheter) is passed. Lateral traction of the skin helps to apply tension and avoid kinking the wire as the

dilator traverses tissue planes.

!

Hold the wire just above the dilator hub, grasp the dilator just above its tip and push it over the

guidewire with a firm corkscrew motion (picture 7). Mild resistance is normal. Excessive resistance may

represent an inadequate skin incision, a malpositioned guidewire, or guidewire or dilator deformation.

Kinking of the guidewire against the dilator is associated with vessel trauma and puncture [47].

!

As described above with needle placement, the opening of the dilator (or dilator/sheath combination)

should be covered, and the patient encouraged to Valsalva to prevent entry of air.

!

Advance the dilator only to the anticipated depth of the subclavian vein, notthe entire length of the

dilator. For the subclavian site, the dilator need only be advanced 3 to 5 cm into the vein depending

upon the thickness of the patients neck.

!

Withdraw the dilator while maintaining the guidewire position within the vessel. Apply direct pressure to

the exit site to maintain hemostasis prior to catheter insertion.

!

Steady traction on the skin during soft-tissue dilatation helps prevent wire kinking. Rotating the dilator

during advancement often facilitates tract dilatation (round dilators only). If resistance is met, it may be

related to a kink in the wire which can be remedied by advancing the wire deeper or withdrawing the

kink into the dilator. Overzealous efforts and guidewire kinking (especially with stiff dilators) risk

traumatic vein injury.

!

Thread the guidewire back through the end-hole of the catheter until it emerges from the distal port and

advance the catheter over the wire into the vessel (picture 9).

!

Resistance to catheter advancement through the soft tissue tract can be overcome by simultaneously

advancing the catheter and wire together for the first 2 to 3 cm. Advancing further risks subclavian vein

injury if the wire is inadvertently kinked. Withdrawal of the catheter and redilation of the tract is

preferred.

!


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In contrast to right-sided catheters, catheters inserted from the left negotiate the angulation of the

brachiocephalic vein to enter the superior vena cava. For large bore catheters used for hemodialysis or

oncology, advancement under fluoroscopic guidance helps minimize the risk of central venous laceration.

The risk of complications is related to the angle of catheter impingement on the superior vena cava [ 9]. From

the left, catheters positioned above the pericardial reflection often abut the weak lateral wall of the superior

vena cava and risk erosion and perforation [52-55]. As such, left-sided catheters should be inserted to an

appropriate length to lie parallel in the long axis of the superior vena cava. This may require catheter tip

placement in the upper right atrium [56-58]. It is also important to realize that catheter tips are not fixed and

migrate 2 to 3 cm with head and arm movement and change in body position [ 59].

Catheter flushing and fixation Once the catheter is in place, the proper function of the catheter should

be confirmed by aspirating blood and subsequently flushing each port with saline (picture 10) [9,60].

The catheter can be secured into place by suturing (2-0 or 3-0 nylon or silk) it to the skin ( picture 11). If more

than 2 cm of catheter remain exposed, it can be sutured to the skin or to a separate catheter anchor that is

often included in the catheter kit. A transparent dressing should be placed over the catheter exit site to

protect it from contamination.

CONFIRMATION OF SUBCLAVIAN CATHETER POSITION Confirmation of subclavian catheter tip

location can use one or more of the following methods: chest radiography, fluoroscopy, and transesophageal

echocardiography (typically intraoperative setting) [61-67]. Chest radiography and fluoroscopy are the most

commonly used methods. In general, catheters function well with the tip situated in any major vein. However,

suboptimal tip position may be related to delayed complications.

Following subclavian access, the position and course of the catheter and tip should be confirmed prior to its

use. When using fluoroscopy for placement, a routine chest radiograph is unnecessary unless clinical

suspicion of pneumothorax/hemothorax is high. If fluoroscopy has not been used, we obtain a postprocedure

chest radiograph in non-life-threatening situations. If immediate catheter use is needed, venous positioning

(but not tip position) can be confirmed with transduction of the central venous pressure, display of the central

venous waveform or via ultrasound. Bedside ultrasound is under investigation as an alternative modality to

confirm catheter placement and detect pneumothorax [68].

The optimal catheter tip position is controversial, and controlled studies are lacking. The distal tip of jugular

catheters should lie in the lower superior vena cava [2,5]. To minimize the likelihood of cardiac

complications, some guidelines recommend catheter tip position outside the right atrium and above the

pericardial reflection. The right superior heart border on chest radiography is not a reliable determinant of

right atrial position [69]. The carina and right tracheobronchial angle represent reliable landmarks for the

pericardial reflection and right-sided catheters should generally be positioned above this point [69-71].

Malposition is common with subclavian access and is often related to an initially misplaced guidewire [1]. If a

catheter is malpositioned within the venous system, it can be used for fluid administration under emergency

circumstances, but should be re-positioned as soon as feasible. In contrast, inadvertent placement of a

catheter into the subclavian artery mandates surgical consultation [28].

If a subclavian catheter tip is positioned too deeply, it can be repositioned at the bedside using sterile

technique. Remove the sutures, withdraw the catheter, and re-suture the catheter into place.

!

If a catheter is not in far enough or is misplaced into the contralateral subclavian or internal jugular

vein, it will need to be replaced over a guidewire under sterile conditions. The portion of a catheter left

out of the body is unsterile and should never be advanced into the patient, not even if it is under a

!


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CATHETER MANAGEMENT The management of central catheters is discussed elsewhere. (See

"Prevention of intravascular catheter-related infections", section on 'Site care'and "Prevention of

intravascular catheter-related infections", section on 'Catheter care'.)

COMPLICATIONS The complications related to subclavian venous access are discussed separately.

(See "Complications of central venous catheters and their prevention".)

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

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Central catheters provide dependable intravenous access and enable hemodynamic monitoring and

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!

For subclavian access, the patient is placed supine or in Trendelenburg position with the arms placed

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!

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!

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!

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!

If a subclavian catheter is placed too deeply, it can be withdrawn at the bedside using sterile

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71.

Topic 15673 Version 6.0


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GRAPHICS

Advantages and disadvantages of central vein approaches

Approach Advantages Disadvantages

External

jugular

Superficial vessel that is often

visible

Coagulopathy not prohibitive

Minimal risk of pneumothorax

(especially with US guidance)

Head-of-table access

Prominent in elderly patients

Rapid venous access

Not ideal for prolonged venous access

Poor landmarks in obese patients

High rate of malposition

Catheter may be difficult to thread

Internal

jugular

Minimal risk of pneumothorax

(especially with US guidance)

Head-of-table access

Procedure-related bleeding

amenable to direct pressure

Lower failure rate with novice

operator

Excellent target using US

guidance

Not ideal for prolonged access

Risk of carotid artery puncture

Uncomfortable

Dressings and catheter difficult to

maintain

Thoracic duct injury possible on left

Poor landmarks in obese/edematous

patients

Potential access and maintenance issues

with concomitant tracheostomy

Vein prone to collapse with hypovolemia

Difficult access during emergencies when

airway control being established

Subclavian Easier to maintain dressings

More comfortable for patient

Better landmarks in obese

patients

Accessible when airway control is

being established

Increased risk of pneumothorax

Procedure-related bleeding less

amenable to direct pressure

Decreased success rate with

inexperience

Longer path from skin to vessel

Catheter malposition more common

(especially right SCV)

Interference with chest compressions

Femoral Rapid access with high success

rate

Does not interfere with CPR

Does not interfere with

Delayed circulation of drugs during CPR

Prevents patient mobilization

Difficult to keep site sterile


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intubation

No risk of pneumothorax

Trendelenburg position not

necessary during insertion

Difficult for PA catheter insertion

Increased risk of iliofemoral thrombosis

US: ultrasound; SCV: subclavian vein; CPR: cardiopulmonary resuscitation; PA: pulmonary artery.

With permission from: Factor P, Sznajder JI. Vascular cannulation. In: Principles of Critical Care,

Hall JB, Schmidt GA, Wood LDH (Eds), McGraw-Hill, New York, 1992. Copyright 1992 McGraw-Hill.

Graphic 71716 Version 6.0


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External landmarks for the infraclavicular

approach to the subclavian vein

UpToDate acknowledges the invaluable assistance of the University of

Massacusetts Medical School, Department of Anatomy and Department of

Emergency Medicine, including Thomas Ellis, MD and Jean Marcelin, MD, for

the photographs of central venous catheter placement.



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Anatomy of the subclavian and internal jugular veins



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Equipment for central venous cannulation

2 percent chlorhexidine skin preparation solution

Sterile gown, gloves, face shield and cap

Sterile gauze pads: 4" x 4"

Sterile drapes

1 percent lidocaine; 5cc

25 Ga. needle with 3cc lock-tip syringe

Seeker needle: 3.5 cm 22 Ga. needle with 5cc slip-tip syringe

Introducer needle: 6 cm 18 Ga. large bore needle with 5cc slip-tip syringe

J-tip guidewire

Transduction catheter: 6 cm 18 Ga. catheter

Transduction tubing

Tissue dilator

Sterile catheter flush solution

Sheath

Catheter or other device (eg, port, pulmonary catheter)

Sterile sleeve for the catheter

2-0 silk sutures

Sterile dressing

Equipment needed for central venous cannulation, in order of use during procedure. For

certain procedures (eg, pulmonary artery catheter placement) additional supplies (drapes,

gowns) or additional catheter sets (introducer, sheath, pulmonary catheter, other venous

device) may be needed.



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Technique of central venous catheterization

Identify vessel or pertinent landmark

Prepare the site by scrubbing widely with antiseptic solution

Drape the site with sterile towels and surgical drapes

Infiltrate the skin with 1 percent lidocaine

Cannulate the vein using the introducer needle

Confirm position of needle by easy aspiration of venous blood; if doubt exists regarding

venous versus arterial cannulation, transduction of pressures or blood gas analysis is

recommended

Remove syringe from needle hub

Insert J-tipped guidewire through the needle into the vein and gently advance the wire;

neverforce the wire

Remove the needle while maintaining control of the guidewire

Make a small skin nick contiguous with the wire using an upward-facing scalpel blade

Advance the dilator over the wire using a twisting motion; always hold the guidewire

Withdraw dilator while guidewire is stabilized

Thread the catheter over the guidewire; always hold the guidewire

Stabilize the catheter and remove the guidewire

Evaluate ease of aspiration and flushing from each port of catheter

Suture the catheter securely, dress site with sterile technique and topical antiseptic ointment



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Infraclavicular approach to the subclavian vein

The midpoint approach to cannulation of the subclavian vein is most common. Insert

the needle 2 to 3 cm inferior to the midpoint of the clavicle. Advance the needle

aiming just deep to the suprasternal notch, keeping the needle parallel to the ground.



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Supraclavicular approach to the subclavian vein

The supraclavicular approach allows ready access to the subclavian vein. The point of

needle entry lies 1 cm posterior to the sternocleidomastoid and 1 cm superior to the

clavicle. Be sure the angle of the needle is depressed 10 to 15 degrees below the

coronal plane (ie, needle tip aimed upwards). Advance the needle behind the medial

clavicle along a trajectory directed just below the contralateral nipple.



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External landmarks for the supraclavicular

approach to the subclavian vein







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Finder needle for central line placement

This photograph depicts the use of a finder needle to locate the internal

jugular vein.







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Needle insertion for the middle approach to

subclavian vein

In the middle approach to the subclavian vein, the needle is inserted 2

to 3 cm inferior to the midpoint of the clavicle. The needle is advanced

while aiming for a point just deep to the suprasternal notch.







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Needle insertion for central venous catheter

placement using the supraclavicular approach

When using the supraclavicular approach for central venous catheter

placement, it is important that the needle be oriented properly. It

should lie 10 to 15 degrees below the coronal plane and oriented to

bisect the angle between the clavicle and the sternocleidomastoid. The

needle should not be inserted too deeply; the subclavian vein generally

lies 1 to 1.5 cm deep to the insertion point.







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Right atrial pressure tracing

This schematic diagram shows the different components of the right

atrial pressure tracing. A simultaneous ECG is shown to demonstrate the

timing of the different components.

Redrawn from Gore, JM, Alper, JS, Benotti, JR, et al. Handbook of

hemodynamic monitoring, 1st ed, Boston, Little Brown & Co, 1985.



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Guidewire with J tip for central venous catheter

placement

Proper orientation of the J tip towards the superior vena cava helps

prevent improper placement of central venous catheters. For subclavian

catheters, the J tip is oriented caudally; for internal jugular catheters,the J tip is oriented medially.







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Placement of a guidewire for a central venous

catheter







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Insertion of soft tissue dilator for central venous

catheter placement

The soft tissue dilator is advanced over the guidewire using a corkscrew

motion. Mild resistance is normal. The dilator does NOT need to be

advanced its entire length, but only to the anticipated depth of the

vessel.







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Central venous catheter being threaded onto

guidewire







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Central venous catheter being advanced over

guidewire

As the catheter is advanced, the guidewire emerges from the distal port.

Control should be maintained of both the catheter and the guidewire

throughout this process.







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Aspiration following central venous catheter

placement

Following placement of the catheter, blood should be aspirated from

each port and then each port should be flushed.







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Central venous catheter sutured in place

When suturing central venous catheters in place, avoid knots that place

excessive pressure on the skin, which can lead to skin necrosis.

UpToDate acknowledges the invaluable assistance of the University ofMassacusetts Medical School, Department of Anatomy and Department of





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Disclosures:Alan C Heffner, MD Speaker's Bureau: Edwards Lifesciences [Hemodynamic monitoring, shock, sepsis

(Hemodynamic monitoring devices)]. Consultant/Advisory Boards: Edwards Lifesciences [Hemodynamic monitoring, shock, sepsis

(Hemodynamic monitoring devices)]. Mark P Androes, MD Nothing to disclose. Allan B Wolfson, MD Nothing to disclose. John F

Eidt, MD Nothing to disclose. Joseph L Mills, Sr, MD Grant/Research/Clinical Trial Support: NIH Institute of Aging (abdominal aortic

aneurysm study). Consultant/Advisory Boards: AnGes (critical limb ischemia); Cesca Therapeutics (critical limb ischemia). Speaker:

Gore (bypass seminar [Polytetrafluoroethylene]). Other financial interests: Elsevier (vascular surgery textbooks). Kathryn A Collins,

MD, PhD, FACS Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vettingthrough a multi-level review process, and through requirements for references to be provided to support the content. Appropriately

referenced content is required of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

Disclosures


Placement of Subclavian Venous Catheters

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