Central Venous Access via Subclavian Approach to Subclavian Vein

Updated: Aug 14, 2017
  • Author: E Jedd Roe, lll, MD, MBA, FACEP, FAAEM; Chief Editor: Vincent Lopez Rowe, MD  more...
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Overview

Background

First described in 1952, central venous catheterization, or central line placement, is a time-honored and tested technique of quickly accessing the major venous system. Its benefits over peripheral access include greater longevity without infection, line security in situ, avoidance of phlebitis, larger lumens, multiple lumens for rapid administration of combinations of drugs, a route for nutritional support, fluid administration, and central venous pressure monitoring.

Overall complication rates range up to 15%, [1, 2, 3, 4] with mechanical complications reported in 5-19% of patients, [5, 6, 7] infectious complications in 5-26%, [1, 2, 4] and thrombotic complications in 2-26%. [1] These complications are all potentially life-threatening and, invariably, consume significant resources to treat.

Placement of a central vein catheter is a common procedure, and house staff require substantial training and supervision to become facile with this technique. A physician should have a thorough foreknowledge of the procedure and its complications before placing a central vein catheter.

Compared with femoral site access, internal jugular or subclavian access was associated with a lower risk of catheter-related bloodstream infections (CRBSIs) in earlier studies, but subsequent studies (since 2008) found no significant differences in the rate of CRBSIs between these three sites. [8]

The subclavian approach remains the most commonly used blind approach for subclavian vein cannulation. Its advantages include consistent landmarks, increased patient comfort, and lower potential for infection or arterial injury compared with other sites of access.

The advent of bedside ultrasonography has changed the overall technique of the placement of central venous catheters in both the internal jugular vein and the femoral vein. However, the use of this modality for subclavian routes has been infrequently studied, though there are some reports suggesting that it is feasible and safe.

Because of the anatomy of the subclavian approach, there is little room to effectively position the transducer while manipulating the needle. With the advent of newer transducers, however, reports are emerging of effective ultrasound-guided techniques. [9]  Compared with the studies evaluating the internal jugular approach, the studies evaluating ultrasound-guided approaches to the subclavian vein are fewer in number and lower in quality; nevertheless, these early results are encouraging with respect to patient safety and quality. [10, 11]

The physician’s experience and comfort level with the procedure, however, are the main determinants as to the success of the line placement in cases with no other patient-related factors that may increase the incidence of complications.

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Indications

Indications for central venous access via the subclavian approach to the subclavian vein include the following:

  • Volume resuscitation
  • Emergency venous access
  • Nutritional support
  • Administration of caustic medications (eg, vasopressors)
  • Central venous pressure monitoring
  • Transvenous pacing wire introduction
  • Hemodialysis
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Contraindications

Absolute contraindications to central venous access are as follows:

  • Distorted local anatomy (eg, vascular injury, prior surgery, radiation history)
  • Infection at insertion site

Relative contraindications to central venous access are as follows:

  • Presence of anticoagulation or bleeding disorder
  • Patient who is excessively underweight or overweight
  • Uncooperative patient
  • Current or possible thrombolysis

Absolute contraindications to the subclavian approach are as follows:

  • Trauma to the ipsilateral clavicle, anterior proximal rib, or subclavian vessels
  • Coagulopathy (direct pressure to stop bleeding cannot be applied to the subclavian vein or artery, because of their location beneath the clavicle)

Relative contraindications to the subclavian approach are as follows:

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