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Subclavian venous acess

Ultrasound guided

Ultrasound can be used to enhance venous access to the subclavian vein. While the ultrasound-based approach is not the default standard, it can still be a great asset in many cases where the anatomy and vasculature of the upper torso is non-standard and/or where the risk of pneumothorax may itself be a substantive risk to the patient.


It is notable to highlight that access is actually through the axillary vein anatomically, as the subclavian vein cannot be seen under the clavicle with ultrasound. 

The following section will highlight key steps in this process and finish with a video tutorial.

Section contributors: Dr. Leon Byker, Dr Brian Buchanan

Scanning approach

With the probe held to capture the para-sagittal plane with the marker towards the head, the clavicle is seen in cross-section (yellow). Ensuring the clavicle is captured as part of this image helps to ensure clear orientation. There is acoustic shadowing below the clavicle, and the subclavian vessels proper cannot be seen (they cross under the clavicle). More commonly the probe is placed over the distal third over the clavicle and swept inward towards the sternum. From this distal aspect near the humeral head, the axillary vein is seen, caudal to the clavicle, and this vein will become the subclavian vein as it crosses below the clavicle. Usually the subclavian and axillary vein is also caudal to the subclavian and axillary artery. The following image shows a para-sagittal cross section of the right clavicle with the clavicle (yellow), subclavian artery (red) and subclavian vein (blue).

Proximity to the lung

Be aware that whether your approach is blind or ultrasound-guided, the axillary and subclavian is in very close proximity to the pleural lining. Be sure to keep to monitor the needle tip to prevent entering the pleural space.

Site selection

Select the area with the minimal distance between the chest wall and the axillary vein. Again, be vigilant of the depth, so as to prevent passing through the back wall of the vessel and into the lung itself.  Ultrasound cannot be used to pass the needle into the subclavian vessel proper as the vein is beneath the echogenic bony cortex of the clavicle.

 

Confirmation of wire placement

Short axis

long axis

Video tutorial

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