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Tags: vascular access

Subclavian CVC

Most advantages of venipuncture derive from the anatomic properties of the subclav- ian and innominate veins:

1. constant position and easy access
2. large diameter
   • (12 to 25 mm. for the subclavian and 15 to 40 mm. for the innominate vein in the adult)
3. absence of valves
4. walls consisting of a thin tunica muscularis reinforced by a thick tunica fibrosa and adhering, through an extension of the fascia colli media, to the adjacent ligaments, fasciae, and periosteum.
   • Such veins cannot constrict, collapse, or be displaced, and remain open even in shock and death

Right vs Left access

• Right
  • ↑ risk of tip malposition ∵ acute angle
• Left
  • risk of thoracic duct injury
  • ? ↑risk of PTx due to apex higher on Lt

Supraclavicular approach

Since Aubaniac’s original description in 1952, subclavian vein catheterization via the infraclavicular approach has become a well-established technique

In 1965 an alternate supraclavicular approach was described by Yoffa

Reasons to prefer supraclavicular approach over the infraclavicular technique include:

• well-defined insertion landmark (the clavisternomastoid angle)
• shorter distance from skin to vein
• larger target area
• straighter path to the superior vena cava
  the supraclavicular approach less often necessitates interruption of CPR or tube thoracostomy than the infraclavicular method

The point of needle insertion was identified 1 cm cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head of the sternocleidomastoid muscle with the superior margin of the clavicle (claviculosternocleidomastoid angle)

The direction of the needle was indicated by the line that bisects the claviculosternocleidomastoid angle with elevation 5–15 degrees above the coronal plane

the right claviculosternocleidomastoid angle was the preferred catheterization site because of the absence of the thoracic duct and a more direct route of the subclavian and innominate veins on the right

orient the bevel to open caudally so as to facilitate the caudal progression of the guide wire down the vein toward the right atrium

The needle should be virtually parallel to the chest wall in the coronal plane

In the technique, first described by Yoffa in 1965, the needle is directed at an angle of 45° from the sagittal plane and 15° anterior from the coronal plane. Newer literature using 3-dimensional CT have shown higher success rates by placing the needle at the clavisternomastoid angle and directing the needle 10° from the sagittal plane and 35° posteriorly from the coronal plane. This change allows for the shortest distance to the target vessel and for the first rib to act as a physical barrier to reduce the risk of pneumothorax

References

Subclavian Venipuncture A Review

Anatomy and Physiology of Venous System Vascular Access Implications

Supraclavicular Subclavian Vein Catheterization The Forgotten Central Line

Supraclavicular Approach Is an Easy and Safe Method of Subclavian Vein Catheterization Even in Mechanically Ventilated Patients Analysis of 370 Attempts

Critical Points: supraclavicular subclavian central venous catheter technique on Vimeo