Subclavian Vein Cannulation Research Articles

Technique of endovascular repair of iatrogenic subclavian artery injury following subclavian vein catheterization

The iatrogenic subclavian artery injury is a rare but potentially serious complication of subclavian vein cannulation. The use of endovascular techniques is an alternative to surgical repair especially in patients with concomitant diseases in whom immediate, potentially large surgery would be associated with a high risk of perioperative complications. This article discusses technical aspects of endovascular repair of iatrogenic injury of subclavian artery with implantation of covered stents based on two cases. Author’s experience and data from literature suggests that endovascular management including covered stent implantation is safe and effective treatment and should be considered as a method of choice especially among patients in poor general condition and/or major comorbidities.

Effect of shoulder positioning on ultrasonic visualisation of the subclavian vein in healthy adults: A prospective observational study

Introduction: Ultrasound guidance is commonly used during central venous cannulation. Subclavian vein is a commonly chosen site, but previous studies found varying results in the ideal positioning of the shoulder for subclavian vein cannulation. The objective of this study is to determine which shoulder position results in the greatest cross-sectional area of the right subclavian vein for cannulation. Methods: In this prospective observational study, ultrasound was performed on healthy adult volunteers to visualise the right subclavian vein in three different shoulder positions: neutral, abduction and retraction. A blinded independent investigator measured the cross-sectional areas by computer software using planimetry method. Statistical analysis was performed by one-way repeated measures analysis of variance. Results: Forty-four adults participated in the study. The mean cross-sectional area of the right subclavian vein in shoulder neutral, abduction and retraction positions were 1.05 ± 0.33 cm2, 1.01 ± 0.31 cm2 and 0.82 ± 0.28 cm2, respectively. When compared to shoulder retraction, the cross-sectional areas were significantly increased in shoulder neutral ( P < 0.01) and abduction ( P < 0.01) positions. There was no significant difference between shoulder neutral and abduction position ( P = 0.71). Conclusion: Positioning the shoulder in neutral or abduction results in the greatest cross-sectional area of the right subclavian vein and may be more ideal for ultrasound guided cannulation.

Cannulation of the subclavian vein using real-time ultrasound guidance.

Cannulation of the subclavian vein has many advantages when compared to other anatomical sites for central venous access. Difficulty in its ultrasonic visualisation, and the perceived consequent 'higher' complication rate, mean that this approach has fallen out of favour. This barrier, however, may now have disappeared. In this article, we discuss the indications, contraindications and complications associated with subclavian vein cannulation, and present an ultrasound-guided approach to infraclavicular subclavian cannulation.

Real-time Ultrasound-guided Puncture of Subclavian Vein for Chemo-port Implantation

Introduction: There is no consensus regarding preferred site for central vein cannulation. [1] The jugular vein is the most “popular site” for central vein cannulation and is the “preferred site” for temporary hemodialysis. [2] The subclavian vein is less “infection-prone” but more likely to cause pneumothorax. [3] In case of chemo-port implantation, anatomical landmark puncture (ALP) of subclavian vein or cephalic vein exploration (CVE) at delto-pectoral groove have been the more “convenient” and “preferred” methods to avoid unaesthetic two incisions and visible subcutaneously-tunneled catheter. Recent evidence suggests that real-time ultrasound guided puncture (UGP) of subclavian vein could lower pneumothorax rate from 1-6% to 0%. [4] The safety, successful cannulation rate and pitfalls of this new procedure are our concerns. Methods: From Oct.13rd, 2018, all patients scheduled for chemo-port implantation were enrolled for clinical trial of UGP for subclavian vein cannulation. The exclusion criteria included surgical site skin infection or tumor invasion, uncorrectable coagulopathy and known occluded central veins. The preoperative sonography reveals diameter of target vein (DTV), skin-to-anterior wall of target vein distance (SAVD) and diameter change along with inspiration. The cancer type, laterality of chemo-port, positioning and body mass index (BMI) of patients, attempts of puncture, pain score during puncture, conversion rate and procedure-related complications were recorded. Results: Total 77 patients, 88.3% female, aged 31-81(mean 54.6) underwent UGP of deep vein at subclavian region for chemo-port implantation. 59.7% of target veins were at left side and they included 68 subclavian veins, 5 axillary veins and 4 cephalic veins at clavipectoral fascia. 98.7% of operations were performed under local anesthesia. The diversity of cancer types included 47 breast cancer, 10 colon cancer etc. BMI ranged from 18.1 to 33.4 ( 24.2± 3.6). DTV and SAVD were 8.5±1.7 mm and 19.4±4.7 mm respectively. Severe subclavian vein collapse during inspiration was found in 25% patients. 54.4% patients were put on Trendelenburg position, 7.4% with shoulder cushioned and none with shoulder shrugging. The success rate of UGP was 90.9% with 6.5% converted to ALP and 2.6% to CVE. The mean attempts of UGP was 2.0±1.9. The pain score during UGP was 3.5±2.0. The total procedure time was 27.7±8.0 minutes. There is no statistically difference between failed group and success group in age, BMI, SAVD, but there is difference in DTV (p=0.0247). [Table 1] There was one pneumothorax (1.3%) found after operation and remitted spontaneously without tube drainage. The Kaplan-Meier curve of patient survival and function of chemo-port has been 100% without re-intervention due to infection or obstruction. Conclusion: The UGP for subclavian vein cannulation is a new technique for a surgeon familiar with ALP. It has opened the 3rd eye of the surgeon to see the advancement of the needle tip and the dramatic change of vein diameter along with the inspiration in our 25% patients. The success rate and complications are fair in our study. The DTV is the main factor for cannulation failure.Table 1comparison of failure group and success groupTable 1comparison of failure group and success group Disclosure: Nothing to disclose

Ultrasound- versus landmark-guided subclavian vein catheterization: a prospective observational study from a tertiary referral hospital

This was a single-center, observational, prospective study designed to compare the effectiveness of a real-time, ultrasound- with landmark-guided technique for subclavian vein cannulation. Two groups of 74 consecutive patients each underwent subclavian vein catheterization. One group included patients from intensive care unit, studied by using an ultrasound-guided technique. The other group included patients from surgery or emergency units, studied by using a landmark technique. The primary outcome for comparison between techniques was the success rate of catheterization. Secondary outcomes were the number of attempts, cannulation failure, and mechanical complications. Although there was no difference in total success rate between ultrasound-guided and landmark groups (71 vs. 68, p = 0.464), the ultrasound-guided technique was more frequently successful at first attempt (64 vs. 30, p < 0.001) and required less attempts (1 to 2 vs. 1 to 6, p < 0.001) than landmark technique. Moreover, the ultrasound-guided technique was associated with less complications (2 vs. 13, p < 0.001), interruptions of mechanical ventilation (1 vs. 57, p < 0.001), and post-procedure chest X-ray (43 vs. 62, p = 0.001). In comparison with landmark-guided technique, the use of an ultrasound-guided technique for subclavian catheterization offers advantages in terms of reduced number of attempts and complications.

Influence of Cannulation Point on Infraclavicular Subclavian Vein Catheterization: A Clinical Trial.

BackgroundChoosing a proper approach to subclavian vein cannulation is a challenge for physicians. However, percutaneous infraclavicular subclavian vein cannulation is now an acceptable technique.ObjectivesThe present study was performed to compare the success rate and complications of subclavian vein cannulation using the midpoint technique and the lateral technique.MethodsIn this prospective randomized clinical trial, we randomly assigned 440 patients undergoing subclavian vein cannulation to either midpoint approach or lateral approach groups from April 2018 to February 2019. The complications and success rates of catheterization were compared between the two approaches. The data were analyzed using SPSS software (version 20).ResultsUnlike the first attempt of catheterization, the success rate was significantly higher in the midpoint technique (75 %) than in lateral technique (39%) in the second attempt (P = 0.003). The overall success rates were 96.8% and 88.6% in the midpoint approach and lateral approach, respectively. A significant difference was observed between the two techniques in the overall success rate (P = 0.001). Inadvertent subclavian artery puncture occurred in 26 (5.9%) patients including 3 (1.4%) patients in the midpoint technique and 23 (10.5%) patients in the lateral technique. In 19 (4.3%) patients, malposition of the catheter tip occurred, including 14 (6.4%) in the midpoint approach and 5 (2.3%) in the lateral approach. There was a significant difference between the two approaches in malposition and subclavian artery puncture (P = 0.035 and P = 0.0001, respectively). There were no significant differences between the two techniques in other complications.ConclusionsThis investigation showed that the midpoint approach was more appropriate than the lateral approach for infraclavicular subclavian vein catheterization with landmark-based techniques.

Evaluation of a Novel Bony Landmark-Based Method for Teaching Percutaneous Insertion of Subclavian Venous Catheters in Pediatric Patients.

Surgical trainees performing subclavian vein (SCV) cannulation often incorrectly perceive needle trajectory and anatomical relations. As surface landmark-based methods derived from adult surgical practice may be less effective in younger patients, we developed and evaluated a novel bony landmark-based method for teaching SCV cannulation for central venous access device (CVAD) placement in children. Over 2 sequential 3-year periods, pediatric surgical trainees were taught infraclavicular SCV cannulation via surface- and bony-landmark approaches, respectively. We prospectively recorded patient, surgeon and operative details on all Hickman line and port-a-cath insertions placed by trainees as the first surgeon via percutaneous infraclavicular SCV puncture and compared procedural outcomes and complications across both periods. Of 271 cases included in the study, trainees performed 52 (50.5%) and 92 (54.8%) procedures in the first and second periods, respectively. Patients in both periods did not differ by gender, disease, CVAD device, or prior CVAD, chemotherapy or infection status. In the second (bony landmark) period, although patients were younger (6.0 vs. 8.7years, P = 0.003) mean procedural duration was shorter (42.5 vs. 58.3min, P < 0.001). Also, cannulation attempts and complication rates did not differ significantly between study periods (P = 0.257 and 1.0, respectively). With the bony landmark approach, trainees could perform the procedures faster despite operating on younger patients, without impacting complication rates and cannulation attempts. Bony landmarks may better approximate SCV position across a range of ages, thus improving the consistency of SCV cannulation in CVAD placements in children.

Variant communication of phrenic nerve in neck.

Variations of the phrenic nerve gain importance in the context of subclavian vein cannulation, implanted venous access portals and supraclavicular nerve block for regional anaesthesia. Some of the variations of phrenic nerve are very common and may have implications even while performing very simple and routine procedures. During routine dissection in the Department of Anatomy, an anatomical variation was observed in the course of the phrenic nerve in an adult male cadaver. On the right side, phrenic nerve in its early course in the neck, close to its origin was giving a communicating branch to the upper trunk of the brachial plexus. Further course of the phrenic nerve was typical. On the left side, no such communication between phrenic nerve and brachial plexus was observed. A thorough knowledge of the anatomical variations and standard anatomy of phrenic nerve is a necessity for the safe and efficient practice of regional anaesthesia.

PG - 02: A Randmized Comparison of Ultrasound Guided Subclavian Vein Cannulation in two Different Arm Positions in Mechanically Ventilated Patients

PG - 02: A Randmized Comparison of Ultrasound Guided Subclavian Vein Cannulation in two Different Arm Positions in Mechanically Ventilated Patients

Influence of arm position during infraclavicular subclavian vein catheterization in coronary artery bypass graft surgery.

Introduction: Percutaneous subclavian vein catheterization via infraclavicular approach is one of the most widely used cannulation techniques for inserting catheters into a central vein. The aim of this study was to evaluate influence of arm position during infraclavicular subclavian vein catheterization with landmark-based technique in coronary artery bypass graft (CABG) surgery. Methods: Between September 2017 and June 2018, this prospective randomized clinical trial was performed in 320 patients. The patients were randomly assigned to the Neutral group (the arms kept by the side) or Abduction group (the arm was abducted to 90°). The success and complication rates were compared in the two groups. The data were analyzed using SPSS software. Results: In the first attempt of subclavian vein cannulation, the success rate had no significant difference between the two groups (P = 0.185). In the second attempt of catheterization, the success rate in Abduction group (40.5%) was lower than Neutral group (81.2%). The overall success rate in two attempts were (84.4%) in the Abduction group and (96.2%) in the Neutral group. There was a significant difference between two groups in the second and overall success rates (P = 0.0001). In 34 (10.6%) patients, subclavian artery puncture occurred, 30 (18.8%) in the Abduction group and 4 (2.5%) in the Neutral group. There was a significant difference between two groups (P = 0.0001). Pneumothorax was occurred in 15 (9.4%) in the Abduction group and 3 (1.9%) in the Neutral group. There was also a significant difference between two groups (P = 0.004). The differences in other complications on two groups were statistically insignificant. Conclusion: Compared with Abduction group, the Neutral group resulted in higher success rate and fewer subclavian artery puncture and pneumothorax. The incidences of other complications were similar on both groups.

Real-time ultrasound-guided axillary vein cannulation in children: a randomised controlled trial.

The axillary vein is a good site for ultrasound-guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real-time ultrasound-guided axillary vein cannulation with conventional infraclavicular landmark-guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound-guided axillary vein (axillary group) or landmark-guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first-attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25-6.48, p=0.010). The first-attempt success rate was 46% for the axillary group and 40% for the landmark group (p=0.274) and median time to cannulation was 156s for the axillary group and 180s for the landmark group (p=0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p=0.08). We conclude that axillary vein cannulation using a real-time ultrasound-guided in-plane technique is useful and effective in paediatric patients.

Comparison of Ultrasonogram (USG)- Guided Supraclavicular Approach vs Infraclavicular Approach for Subclavian Vein (SCV) Cannulation

Comparison of Ultrasonogram (USG)- Guided Supraclavicular Approach vs Infraclavicular Approach for Subclavian Vein (SCV) Cannulation

A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach.

The aim of this study was to compare the success rate and safety of short-axis versus long-axis approaches to ultrasound-guided subclavian vein cannulation. A total of 190 patients requiring central venous cannulation following cardiac surgery were randomized to either short-axis or long-axis ultrasound-guided cannulation of the subclavian vein. Each cannulation was performed by anesthesiologists with at least 3years' experience of ultrasound-guided central vein cannulation (>150 procedures/year, 50% short-axis and 50% long-axis). Success rate, insertion time, number of needle redirections, number of separate skin or vessel punctures, rate of mechanical complications, catheter misplacements, and incidence of central line-associated bloodstream infection were documented for each procedure. The subclavian vein was successfully cannulated in all 190 patients. The mean insertion time was significantly shorter (p=0.040) in the short-axis group (69±74s) than in the long-axis group (98±103s). The short-axis group was also associated with a higher overall success rate (96 vs. 78%, p<0.001), first-puncture success rate (86 vs. 67%, p=0.003), and first-puncture single-pass success rate (72 vs. 48%, p=0.002), and with fewer needle redirections (0.39±0.88 vs. 0.88±1.15, p=0.001), skin punctures (1.12±0.38 vs. 1.28±0.54, p=0.019), and complications (3 vs. 13%, p=0.028). The short-axis procedure for ultrasound-guided subclavian cannulation offers advantages over the long-axis approach in cardiac surgery patients.

Ultrasound-Guided Subclavian Vein Cannulation in Low Birth Weight Neonates.

Central venous access in critically ill, small infants remains technically challenging even in experienced hands. Several vascular accesses exist, but the subclavian vein is often preferred for central venous catheter insertion in infants where abdominal malformation and/or closure of the vein preclude the use of umbilical venous catheters, as catheterization of the subclavian vein is easier in very short necks than the internal jugular vein for age-related anatomical reasons. The subclavian vein approach is yet relatively undescribed in low birth weight infants (i.e., < 2,500 g), and this study aims to explore the feasibility of this technique in very small infants. Retrospective data collection of prospectively registered data on central venous catheter insertion in infants. Neonatal ICU and PICU at a university hospital. One hundred and five newborn children hospitalized in at the ICU. An ultrasound-guided supraclavicular approach was applied on all infants who had an subclavian vein catheterization during a 30-month period from January 2013 to July 2015. One hundred seven supraclavicular subclavian vein catheters were placed in 105 children weighing less than 5,000 g. Among those, 40 patients weighed less than 2,500 g and 10 patients weighed less than 1,500 g. Successful central venous catheter insertion, defined as the correct placement of a functional double-lumen catheter (3F or 4F), was obtained in 97.3%. All three registered failed attempts were due to hematomas from venous bleeding and occurred in infants weighing greater than 2,500 g. No case of accidental arterial puncture or pleural puncture was registered. This large series of subclavian vein catheterizations in small infants demonstrates the feasibility of subclavian vein catheterizations even in very small neonates weighing less than 1,500 g.

A Novel Technique of Subclavian Artery Cannulation for Venoarterial Extracorporeal Membrane Oxygenation.

The common femoral artery is the standard site for immediate vascular access when initiating adult venoarterial extracorporeal membrane oxygenation. However, this approach is fraught with problems such as femoral artery occlusion, distal limb ischemia, reperfusion injury resulting in compartment syndrome, retroperitoneal hemorrhage, thrombosis, embolization, and most importantly, pulmonary edema. Here, we show our preference of using the subclavian artery with a side graft as a different cannulation technique for outflow of extracorporeal membrane oxygenation, which can avoid complications associated with different access techniques. Between September 2013 and December 2014, our group established venoarterial extracorporeal membrane oxygenation via subclavian artery-percutaneous femoral vein cannulation in 11 patients (81.1% men). Mean age was 33 ± 11.1 years (range, 16-55 y). For this technique, the subclavian artery was slung by retrotapes (Retract-o-Tape; Quest Medical Inc. Allen, TX, USA) proximally and distally before arteriotomy. An 8-mm polyethylene terephthalate (Dacron) graft was then sutured in "end-to-side" fashion. The proximal retrotape was removed, and the distal retrotape was passed through a snare. This maneuver allowed us to manage distal flow of subclavian artery by tightening this tape, thus avoiding complications associated with right arm hyperperfusion. After venoarterial extracorporeal membrane oxygenation was established, central venous pressure and lactate levels decreased, and improvements in arterial blood-gas parameters were maintained. Our protocol for venoarterial extracorporeal membrane oxygenation cannulation uses the subclavian artery for arterial access and provides a safe and perhaps improved means for providing venoarterial extracorporeal membrane oxygenation support.

Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back.

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be preferred. This approach allows for direct visualization of needle advancement, which reduces risk of complications and improves successful placement. Infraclavicular SCV cannulation requires simultaneous use of US during needle advancement, but for an inexperienced operator, it is more easily learned compared to the traditional landmark approach. In this article, we review the evidence supporting the use of US guidance for SCV catheterization and discuss technical aspects of the procedure itself.

Effectiveness and complications of ultrasound-guided subclavian vein cannulation in children and neonates

BackgroundThe ultrasound (US)-guided supraclavicular approach to subclavian vein (Sup-SCV) catheterisation in children has recently been described and evaluated in a small cohort. The aim of this study was to assess this technique in a large paediatric cohort including neonates. MethodsWe conducted a prospective observational study between November 2010 and December 2013 which included 615 children divided into two groups according to their weight: Group 1≤5kg (n=124), Group 2>5kg (n=491). All procedures were performed under general anaesthesia by an anaesthesiologist or a supervised resident. The success rates of catheter insertion, the number of punctures required, the procedure time, and the complication rates were analysed. ResultsSup-SCV catheterisation was successful in 98% of the cases and was higher in Group 2 than in Group 1 (99.4% versus 92.7%, P<0.001). The success rate after the first attempt was higher and the incidence of multiple attempts (≥3 punctures) was lower in Group 2 than in Group 1 (84.2% versus 64.5%, P<0.001 and 4.5% versus 19.4%, P<0.001). The success rate was similar between right and left cannulations (P=0.404), and according to physician experience (P=1.000). Procedure time was fast in both groups with a median time for all procedures of 40 seconds [30–90]. Among the procedures recorded, only five arterial punctures and no cases of pneumothorax were observed. ConclusionUS-guided Sup-SCV catheterisation appears to be fast and safe in children and neonates, even if it remains a little more difficult to achieve in lower-weight patients.

Is There an Ideal Site for Central Venous Catheterization?

Synopsis: In a head-to-head trial investigating the ideal site for central venous catheterization, subclavian vein cannulation resulted in less infection and deep-vein thrombosis, but was associated with more mechanical complications than catherization of the femoral or the jugular veins. Source: Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015; 373(13): 1220–1229.

A case of malpositioned catheter via supraclavicular approach for subclavian vein cannulation: A rare technique revisited.

A case of malpositioned catheter via supraclavicular approach for subclavian vein cannulation: A rare technique revisited.

Subclavian Vein Cannulation Success Rate in Neonates and Children.

Background:Central vein cannulation allows the administration of large volumes of fluids in short times and at high osmolarities for rehydration, volume replacement, chemotherapy, and parenteral nutrition. Percutaneous central venous line insertion has replaced peripheral venous cut-down as the primary mode of short-term venous access in children.Objectives:The aim of our study was to delineate some aspects of this procedure as well as its success rate and relative risk in pediatrics.Patients and Methods:Totally, 3264 subclavian vein cannulations in neonates and children were analyzed regarding successful catheterization attempts and early complication rates after the procedure retrospectively in Mofid Hospital (Tehran, Iran).Results:There were 1340 newborn patients (first 28 days of life) in our study population. In these newborns, only 55 cannulations failed; one patient was complicated with pneumothorax; guide wires malfunctioned in 21 cases; and first- attempt cannulation success was reported in only 981 cases. In the remaining 1924 patients, between one month and 8 years old, only 14 attempts at the cannulation of the subclavian vein failed and 1655 cases had first-attempt cannulation success.Conclusions:The cannulation of the central vein in neonates and children in a skilled hand would be performed with great success rate and low complications.