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

Abstract

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.

Figure 1

A) Short axis view of subclavian vein using ultrasound vascular probe. B) Long axis view of subclavian vein using ultrasound vascular probe. SCV, subclavian vein; SCA, subclavian artery

Figure 2

A) Linear transducer is placed perpendicularly and inferior to clavicle. B) Identified anatomical structures include the transverse (short axis) view of subclavian vein (SCV), subclavian artery (SCA) and pleura. C) With SCV centrally positioned, the transducer is rotated 90° clockwise until D) longitudinal view of subclavian vein is obtained. E) Pulse-wave Doppler view of the SCV confirms non-pulsatile flow and identifies the vessel. F) Tilting the transducer cephalad enables the visualization and identification of SCA with pulse-wave Doppler ultrasound for better anatomic orientation.

Figure 3

A) After identification and in-plane alignment of subclavian vein (SCV) on ultrasound, the insertion needle enters the skin at midpoint of the transducer’s small footprint and is advanced within the plane of ultrasound penetration. B), C) and D) The transducer remains in steady position enabling continuous longitudinal view of SCV, and the needle is carefully and slowly introduced with maintenance of needle visualization until the anterior wall of SCV is punctured.