Background
First described by Aubaniac in 1952, central venous catheterization, or central line placement, is a time-honored and tested technique for quickly accessing the major venous system. Benefits over peripheral access include greater longevity without infection, line security in situ, avoidance of phlebitis, larger lumens, multiple lumens for rapid administration of combinations of drugs, a route for nutritional support, fluid administration, and central venous pressure (CVP) monitoring. Central vein catheterization is also referred to as central line placement.
Overall complication rates are as high as 15%, [1, 2, 3, 4] with mechanical complications reported in 5-19% of patients, [5, 6, 7] infectious complications in 5-26%, [1, 2, 4] and thrombotic complications in 2-26%. [1, 8] These complications are all potentially life-threatening and invariably consume significant resources to treat.
Placement of a central venous catheter (CVC) is a common procedure, and house staff require substantial training and supervision to become facile with this technique. A physician should have a thorough foreknowledge of the procedure and its complications before placing a CVC.
The supraclavicular approach was first put into clinical practice in 1965 and is an underused method for gaining central access. It offers several advantages over the infraclavicular approach to the subclavian vein. [9, 10] At the insertion site, the subclavian vein is closer to the skin, and the right-side approach offers a straighter path into the subclavian vein. In addition, this site is often more accessible during cardiopulmonary resuscitation (CPR) and during active surgical cases. Finally, in patients who are obese, this anatomic area is less distorted.
Indications
Indications for obtaining central venous access via the supraclavicular approach to the subclavian vein include the following:
-
Volume resuscitation
-
Emergency venous access
-
Nutritional support
-
Administration of caustic medications (eg, vasopressors)
-
CVP monitoring
-
Transvenous pacing wire introduction
-
Hemodialysis
This approach may be usable as an alternative for placement of cannulae for extracorporeal membrane oxygenation (ECMO). [11]
Contraindications
Absolute contraindications for central venous access include the following:
-
Distorted anatomy (eg, from vascular injury, prior surgery, or previous exposure to radiation)
-
Infection at the insertion site
Relative contraindications for central venous access include the following:
-
Presence of anticoagulation or a bleeding disorder
-
Patient who is excessively underweight or overweight
-
Uncooperative patient
-
Current or possible thrombolysis
Absolute contraindications for the supraclavicular approach include the following:
-
Trauma to the ipsilateral clavicle, neck, or subclavian vessel
-
Coagulopathy (direct pressure to stop bleeding cannot be applied to the subclavian vein or artery, because of these structures' location beneath the clavicle)
Relative contraindications for the supraclavicular approach include the following:
-
Chest-wall or neck deformity
Technical Considerations
Whereas ultrasonographic (US) guidance has proved to be a useful adjunct for internal jugular vein cannulation, its use for subclavian routes has not been as commonly studied. The anatomy of the supraclavicular approach affords relatively little room for effectively positioning the transducer while manipulating the needle. A number of reports, however, have suggested that this application of US guidance is feasible and safe. [12, 13, 14, 15, 16, 17, 18, 19, 20]
Using an ultrasound transducer to locate and superficially mark the vessel before needle insertion is an option. [21]
Outcomes
Nevarre et al published a review of the literature and his own series of 178 supraclavicular line placements. He reported one pneumothorax, one malposition, and two instances of inability to thread the wire. The overall complication rate was 0.56%. This site is likely among the safest approaches for central venous access. [5] (Note, however, that an experienced surgeon performed the procedures reported by Nevarre.)
A study by Muhm et al of 208 supraclavicular lines in 168 hemodialysis patients focused on large-bore catheters such as may be needed for hemodialysis or resuscitation of patients with trauma or sepsis. Complications included one pneumothorax, seven arterial punctures, and two thoracic duct punctures without sequelae. Catheter malpositions occurred only sporadically (1%). Thus, even with large-bore catheters, the supraclavicular approach may be a preferable route of placement. [6]
Czarnik et al reported a high overall success rate (92%) for the supraclavicular approach in 370 patients. Most of the patients (78.4%) were mechanically ventilated during the procedure, and the overall complication rate was 1.7%, including three subclavian artery punctures and three contralateral subclavian vein catheterizations. No life-threatening complications occurred. The authors noted this approach to be another viable site for venous access, even in those being mechanically ventilated. [22]
These studies were encouraging, especially given that a large percentage of the studied patients represented a situation in which the line placement was complicated or difficult. However, the numbers of patients included were small, and the operators were experienced with this technique.
In a meta-analysis of eight randomized controlled trials, Chen et al we evaluated the success rate and complication rate of subclavian venous catheterization performed via the supraclavicular versus the traditional infraclavicular approach. [10] Primary outcome measures were cannulation failure rate and incidence of malposition; secondary outcome measures were cannulation access time and incidence of pneumothorax and artery puncture. Primary outcomes were superior with the supraclavicular approach; secondary outcomes were not significantly different.
In a systematic review (28 studies) aimed at determining the success and complication rates of the supraclavicular approach to the subclavian vein, Nazir et al cited overall success rates in the range of 79-100% and overall complication rates in the range of 0-24.24% (mean, 4.27%). [23] Arterial puncture (1.39%) and catheter malposition (0.42%) were the two most common complications.
-
Central venous catheter equipment. Image courtesy of Wikimedia Commons.
-
Anatomy for approach to subclavian vein.
Tables
|
Internal Jugular |
Subclavian |
Femoral |
Supraclavicular |
Arterial puncture |
6.3-9.1 |
3.1-4.9 |
9.0-15.0 |
0.8-3.36 |
Hematoma |
< 0.1-2.2 |
1.2-2.1 |
3.8-4.4 |
N/A |
Hemothorax |
N/A |
0.1-0.6 |
N/A |
N/A |
Pneumothorax |
< 0.1-0.2 |
1.5-3.1 |
N/A |
0.48-0.56 |
Thrombosis |
7.6 |
1.9 |
21.5 |
N/A |
