Central Venous Access via Supraclavicular Approach to Subclavian Vein Technique

Updated: Apr 20, 2017
  • Author: E Jedd Roe, lll, MD, MBA, FACEP, FAAEM, MSF, CPE; Chief Editor: Rick Kulkarni, MD  more...
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Technique

Supraclavicular Approach to Subclavian Vein

Explain the procedure, benefits, risks, and complications. and obtain signed informed consent.

The key to a successful line placement is meticulous preparation and setup before starting or donning sterile garb. This includes consideration of what equipment may be needed if complications arise. The same preparation technique should be used every time this procedure is performed. 

With the patient appropriately positioned (see Patient Preparation), identify landmarks.

Open the line kit, and position the equipment within easy reach. One may want to retract the J-wire into the plastic loop sheath for easy directing into the introducer needle. Also, uncap the distal lumen, which is typically the brown one.

Prepare the insertion site with the iodine or alcohol solution provided in the kit. This amount of preparation is often inadequate, and a wide area around the insertion site should be liberally prepared with 4 × 4 cm gauze soaked in a povidone-iodine solution. Prepare the neck as well, in case the initial approach fails and another approach must be attempted. A sterile field should extend from the jaw to several fingerbreadths below the clavicle.

Put on sterile mask, gown, and gloves. Drape the patient in a sterile fashion with the insertion site exposed.

Using a generous amount of lidocaine, infiltrate the skin and subcutaneous tissue.

Position the bevel of the introducer needle in line with the numbers on the syringe. Upon insertion, orient the bevel to open caudally so as to facilitate the caudal progression of the guide wire down the vein toward the right atrium.

While continuing to aspirate with the syringe, insert the introducer needle along the 45° bisection of the approximately 90° angle formed by the superior aspect of the clavicle and the lateral border of the sternocleidomastoid. The needle should be virtually parallel to the chest wall in the coronal plane. Beware aspirating air bubbles through the probing introducer needle. This indicates a pneumothorax. (See Tube Thoracostomy.)

If the vein is difficult to locate, remove the introducer needle, flush it clean of clots, and try again. Change insertion sites after three unsuccessful passes with the introducer needle.

When venous blood is freely aspirated, disconnect the syringe from the needle, immediately occlude the lumen to prevent air embolism, and reach for the guide wire. Insert the guide wire through the needle into the vein. If the wire does not pass easily through the needle down the vein, remove the wire, reattach the syringe, and confirm that the needle is still in the lumen of the vein before reattempting the procedure.

Beware a return of red or pulsatile blood. If this occurs, the wire is in an artery.

Advance the wire until it is mostly in the vein or until ectopy is seen on the cardiac monitor. Then, retract the wire about 3-4 cm. Holding the wire in place, withdraw the introducer needle and set it aside.

Use the tip of the scalpel to make a small stab just against the wire to enlarge the catheter entry site.

Thread the dilator over the wire and into the vein with a firm and gentle twisting motion while maintaining control of the wire. Holding the wire in place, remove the dilator. To estimate the distance from the insertion site to the subclavian vein just over the atrium, the catheter can be held over the patient’s chest.

Thread the catheter over the wire, then thread the wire out of the distal (brown) lumen and grasp the wire. Continue to thread the catheter into the vein to the desired length.

Hold the catheter in place, remove the wire, and occlude the open lumen. Attach a syringe with some saline in it to the hub and aspirate blood. Take needed samples, then flush the line with saline and recap. Repeat this step with all lumina.

Verify line placement with chest radiograph. The catheter should end in the vena cava at the manubriosternal angle, not in the right atrium.

Suture the catheter in place. For patient comfort, the clinician may need to anesthetize this area with lidocaine first. Apply a clean dressing.

Next:

Complications

Local site or systemic infection is a major potential complication of this procedure. Multiple studies have shown lower infection rates with the use of maximal sterile-barrier precautions, including mask, cap, sterile gown, sterile gloves, and large sterile drape. This approach has been shown to reduce the rate of catheter-related bloodstream infections (CRBSIs) and to save an estimated $167 per catheter inserted. [6]

Additional potential complications include arterial puncture, hematoma, hemothorax, pneumothorax, and thrombosis (see Table 1 below). [5, 6, 7, 16, 20, 21]

Table 1. Rates of Selected Complications of Central Venous Catheterization [5, 6, 7, 16, 20, 21] (Open Table in a new window)

  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
         

As in other central venous catheter approaches, puncture or laceration of the subclavian artery is theoretically possible. Also, the subclavian vein cannot be compressed; therefore, this approach should be avoided in patients who are anticoagulated.

A hematoma usually requires monitoring only.

Check the chest radiograph for evidence of a hemothorax. If evidence is found, consult a surgeon immediately, and consider tube thoracostomy.

Check a chest radiograph for evidence of a pneumothorax when finished or before switching to the contralateral side after failed insertion on one side.

Catheter-related thrombosis might lead to pulmonary embolism.

Other complications have been reported as well.

An air embolism is caused by negative intrathoracic pressure, with inspiration drawing air into an open line hub. Be sure the line hubs are always occluded, and note that placing the patient in the Trendelenburg position lowers this risk. If air embolism occurs, the patient should be placed in the Trendelenburg position with a left lateral decubitus tilt, which may prevent the movement of air into the right ventricle and onward; 100% oxygen should be administered to speed the resumption of air. If a catheter is located in the heart, aspiration of air should be attempted.

Dysrhythmia is due to cardiac irritation by the wire or catheter tip. Placing a central venous catheter without a cardiac monitor is unwise.

Atrial wall puncture can lead to pericardial tamponade.

If the clinician is not conscientious about maintaining control of the guide wire, it may be lost into the vein and require retrieval by interventional radiology.

Patients who are allergic to antibiotics may experience anaphylaxis upon insertion of an antibiotic-impregnated catheter.

The catheter tip may be too deep. Check for this complication on the postprocedure chest radiograph, and pull the line back if the tip disappears into the cardiac silhouette.

The catheter may be located in the wrong vessel. When the subclavian catheter is not in the correct position, it usually deviates cranially up the internal jugular vein instead of down the subclavian vein. This complication is rare with the supraclavicular approach.

Chylothorax is a possible complication on the left side.

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