To the Editor: Antecubital central venous catheterization remains a valuable technique for many anesthesiologists. A letter recently appearing in your journal described an improved technique for insertion of these catheters [1]. We would like to attach two comments to the letter. First, the technique of insertion of a central line through a short antecubital intravenous catheter was described in your journal in 1987 [2]. Second, we have a different experience with the success rate of that technique compared with the results of Gupta et al. [1]. We looked at the tip position of 90 consecutive percutaneous antecubital central venous catheters (Intracath Registered Trademark 1.7 mm, 61 cm long; Deseret Medical Inc., Parke, Davis & Co., Sandy, UT) inserted prior to surgery in adult patients through a 2.1-mm Insyte Registered Trademark intravenous catheter (Deseret Medical Inc.). Postoperative anterior-posterior chest radiographs showed that 42% of all catheter tips were in the superior caval, brachiocephalic, or subclavian veins. Thirty-three percent of all catheter tips were extrathoracic. The success rate was significantly higher (P < 0.05) for left-sided catheter insertions than for right-sided insertions, and catheterization through the left basilic vein resulted in the highest success rate (51%). Aspiration of blood through the catheters was possible in 87% of all cases, in 90% of intrathoracic catheters, and in 79% of extrathoracic catheters. The major complications were cardiac dysrhythmias in 43% of right ventricular catheterizations and one case of severe Staphylococcus aureus thrombophlebitis. We agree with Gupta et al. that the alleged advantages of central venous catheters include monitoring of central venous pressure and administration of drugs in the avoidance of peripheral thrombophlebitis, and that a right atrial central venous catheter may assist in the treatment of venous air embolism. Also, few anesthesiologists would disagree with Gupta et al.'s statements, that antecubital central venous catheters minimize the risks of pneumothorax and hematoma formation and that the Trendelenburg position may be avoided with this technique in patients who poorly tolerate the head-down position. It is true, also, that the suggested technique allows for manipulations of the central venous catheter without the risk of shearing of the catheter that is associated with the use of a steel cannula. We further agree that antecubital central venous catheterization is an old, but often ignored, technique. However, although Gupta et al. achieved an 85%-90% success rate, failure to achieve correct tip placement occurred in 58% of catheterizations in our study, and the failure rate is quoted in Gupta et al.'s letter to vary from 10% to 40%. In other words, many studies have been unable to confirm the high success rate achieved by Gupta et al., even though the catheter-through-catheter technique was used. We feel that the high rate of misplaced catheter tips consistently reported may be one reason why antecubital central venous catheterization has become "an often ignored technique." If electrocardiograph-assisted positioning of antecubital central venous catheters is not used, a chest radiograph is needed to verify correct tip position, since both respiratory fluctuations in the recorded venous pressure and possible aspiration of blood are unreliable indicators of correct tip placement [3]. Lars P. Wang, MD Ian R. Jenkins, MB ChB D. Neil Watkins, MB BS Sofie Chaudri, MB ChB, FFARACS Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, West Australia 6009, Australia