We report a case of a difficulty inserting a Hickman line that was overcome by asking the patient to perform a Valsalva manoeuvre. A middle-aged woman of short stature weighing 72 kg and BMI 33, required a line for long-term chemotherapy. A left-sided approach was chosen due to previous surgery on her right breast and axilla. We planned to insert a Bard single lumen 6.6 Fr Hickman line (Bard Access Systems, Crawley, UK) into the left axillary or subclavian vein. Ultrasound detected a small deep axillary vein and the subclavian vein was therefore selected. Cannulation was guided by fluoroscopy. The vein was punctured above the first rib using a micropuncture technique and the wire passed readily into the brachiocephalic vein. When the wire was advanced further it repeatedly passed into the ipsilateral internal jugular or the contralateral subclavian vein. Elevating or depressing the shoulders and turning the head made no difference to the course of the wire. Finally, we asked the patient to take a deep breath, hold her nose with her fingers, close her mouth and breath out maximally (like straining when passing stool), after which the wire passed immediately into the superior vena cava. In our experience of inserting over 1000 subclavian and axillary vein Hickman lines we have often encountered difficulty in directing the wire in to the superior vena cava. Indeed, 7% of jugular lines are reported to be misplaced in the axillary vein [1] and 5% of subclavian lines are incorrectly positioned in the ipsilateral jugular vein [2]. Howes and Dell recently reported a difficult central venous line insertion using the right subclavian approach [3] when the guide wire repeatedly passed in to the right jugular vein despite using ultrasound guidance and the superior vena cava could not be cannulated. If this occurs we advise removing the wire and injecting contrast to ensure that the vein is not thrombosed proximally. This is particularly important in patients who have had previous central line catheters as there is a 13% risk of thrombosis after long-term subclavian vein catheters and a 3% risk after internal jugular vein catheters [4]. Repositioning of the patient as described above can often facilitate wire placement but on occasions we have found the Valsalva manoeuvre to be successful. The application of 20 cmH2O of continuous positive airway pressure has been shown to maintain internal jugular vein patency and reduce the incidence of kinking and locking of the guide wire [5]. Asking the patient to take a deep breath may also straighten the great vessels and help wire positioning [6]. Alternatively, specialised directional wires or blockers can be used but are generally reserved for use by a skilled radiologist.