UMEM Educational Pearls

Background:

Ultrasound-guided subclavian central venous catheter (CVC) placement has become a preferred site due to low risk of infection and a low risk of complication.  Complications include arterial puncture, pneumothorax, chylothorax, and malposition of the catheter.  Ultrasound guidance can significantly reduce the risk of these complications aside from catheter malposition.   The most common sites of malposition are in the ipsilateral internal jugular vein or the contralateral brachiocephalic vein.  This study sought to evaluate the rate of catheter malposition between left-and right-sided subclavian vein catheter placement using ultrasound guidance with an infraclavicular approach.

Study:

• Randomized controlled trial, single center, 449 patients
• Excluded patients with pacemaker near the insertion site, infection, patients on anticoagulation, tricuspid valve vegetation, vein thrombus, ports, or a preexisting catheter.
• The primary outcome was the rate of catheter malposition.
• Malposition was defined as not being in the ipsilateral subclavian and brachiocephalic veins and superior vena cava.

Results:

• Catheter malposition occurred in 4.5% in the left-sided group and 13.8% in the right-sided group, OR 0.29 (0.14-0.61 p=0.001). 
• Malposition of the catheter into the ipsilateral internal jugular vein was more common than the contralateral brachiocephalic vein.

Take Home:

For infraclavicular ultrasound-guided subclavian CVC placement, consider using the left-side over the right if no contraindications for left-sided access exist.

Additional Information

The authors proposed anatomical differences in the subclavian veins as the etiology for the difference in malposition rates.  Images are provided in the paper.  Patient positioning may also play a role which the authors commented on and other clinicians have responded to the article with their thoughts.  

Supraclavicular subclavian vein access is also discussed as an alternative option that can provide real-time tracking of the guidewire into the correct location to reduce malposition rates.  

Read More below.

Supraclavicular approach and response to the article:

Kander, Thomas MD, PhD1,2; Adrian, Maria MD, PhD1,3; Borgquist, Ola MD, PhD1,3. Right Subclavian Venous Catheterization: Don’t Throw the Baby Out With the Bathwater. Critical Care Medicine 52(12):p e645-e646, December 2024. | DOI: 10.1097/CCM.0000000000006388

Adrian M, Kander T, Lundén R, Borgquist O. The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study. Anaesthesia. 2022 Jan;77(1):66-72. doi: 10.1111/anae.15534. Epub 2021 Jul 14. PMID: 34260061.

Patient position discussion:

Tokumine, Joho MD, PhD; Moriyama, Kiyoshi MD, PhD; Yorozu, Tomoko MD, PhD. Influence of Arm Abduction on Ipsilateral Internal Jugular Vein Misplacement During Ultrasound-Guided Subclavian Venous Catheterization. Critical Care Medicine 52(12):p e646-e647, December 2024. | DOI: 10.1097/CCM.0000000000006410

References

Shin KW, Park S, Jo WY, Choi S, Kim YJ, Park HP, Oh H. Comparison of Catheter Malposition Between Left and Right Ultrasound-Guided Infraclavicular Subclavian Venous Catheterizations: A Randomized Controlled Trial. Critical Care Medicine. 2024 Oct 1;52(10):1557-1566. doi: 10.1097/CCM.0000000000006368. Epub 2024 Jun 24. PMID: 38912886.