Ultrasound guided subclavian vein cannulation using open door technique

Introduction:

Central venous cannulation remains an important part in management of patients in both ICU

and operation theatre. The use of USG for accessing internal jugular vein and femoral veins

remains far better when compared to subclavian vein owing to its risk. This is mainly because

of the anatomy of subclavian vein where part of its course is obscured by the clavicle in the

neck. Though there are many approaches described in literature to cannulate the SCV using

USG most of it are axillary vein cannulation where the punctures are taken well laterally

below the clavicle and there were no simple and standard scanning method for SCV

cannulation. Through this article we introduce a simple method of scanning for using USG

for SCV cannulation where the puncture is made close to the clavicle and having resemblance

close to the Landmark technique.

Technique:

We used a linear transducer probe with 2.5inch foot length and 3 to 15 MHz frequency with

vascular preset. Clavicle and cephalic vein are used as our reference points. With the patient

in supine position with arms by side and the shoulder in neutral position and operator

standing by the side of patient the linear probe is placed slightly obliquely over the midpoint

of clavicle in a cranio caudal direction with the caudal end of probe pointing towards patient

pubic symphysis (Fig 1). By doing this we would obtain a sonographic view with acoustic

shadowing of clavicle in the middle of the image with or without one or two anechoic circular

structures representing the subclavian vessels (Fig 2). Then the probe is glided laterally to

visualize the course of both SCV and SCA in short axis view and the confluence of cephalic

vein with the axillary vein (Fig 3 and 4). Once the confluence is seen then the probe is glided
medially till the point where the SCA disappears under the clavicle (Fig 5 and 6). At this

point the probe is moved caudally till the cranial end of the probe lies above the clavicle and

the SCV occupies the cranial end of the view (Fig 7 and 8). Now the foot of the probe is fixed

at cranial end with clavicle as a hinge and the probe is rotated gently in clockwise or

anticlockwise direction like opening a door depending on right or left side SCV cannulation

respectively till the transverse view of SCV is converted to longitudinal view (Fig 9 and 10).

At this point probe is tilted slightly caudally to visualize the SCA which is pulsatile and non-

compressible without any respiratory phasic variation of its luminal size and its flow pattern

on colour doppler (Fig 11 and 12). After confirming the SCA and its anatomical orientation

with SCV just by tilting the probe cranially and gliding caudally a little, the probe is

positioned to focus the SCV in longitudinal plane. Try to look for cephalic vein adjoining

with axillary vein if possible, as to avoid the puncture lateral to its confluence with axillary

vein and the movement of pleura with respiration. Now the probe is glided cranially to get the

clavicle acoustic shadow in middle of the sonographic image (as to get the puncture point

close to the clavicle) and the probe is fixed in this position (Fig 13 and 14). At this point, the

operator inserts the needle at the caudal end of the probe at angle of 45 to 60 degree in line

with foot of the probe. The needle trajectory is guided in such a way the tip of needle pierces

the anterior wall of the SCV just before it disappears under the acoustic shadow of clavicle.

During this maneuver dynamically tilt the probe cranio-caudally to look for wrong direction

of the needle towards the artery to prevent inadvertent arterial puncture. Try to keep the

needle tip in vision throughout the procedure so that posterior vessel wall puncture and the

pleural contact can be avoided. Once the vessel is punctured and the guide wire is inserted

probe is placed over medial side of supraclavicular fossa to look for the arching of the guide

wire into the brachiocephalic vein which looks like a waterfall.

Discussion:

Structurally when axillary vein crosses the outer border of first rib it is termed as

subclavian vein but when we look functionally post the confluence of cephalic vein with the

axillary vein there are no major tributaries draining into the axillary vein and our idea is to

place the puncture as close to the clavicle as possible but medial to the cephalic vein

confluence and above the first rib. We have successfully cannulated 20 patients with this

“open door” technique with 100% success rate. We tried this technique in both right and left

SCV (80% and 20% respectively) successfully. There were no major complications like

pneumothorax, arterial puncture, infection, or misplaced catheters. There was also no kinking

or bending of CVC catheter as we have seen in some of the axillary vein cannulations. The

main advantage of this technique is the puncture is taken close to the clavicle (Fig 15 and 16)

so we get adequate length of catheter length to position the CVC tip near RA SVC junction

which is not possible in some of the axillary vein cannulation using standard CVC catheters.

The main drawback of this technique is the needle trajectory with an angle of 45 to 60 degree

which will be difficult during early part of the learning curve. Though the risk of

pneumothorax and arterial punctures are present as it is a dynamic process the risk can be

minimized by using this technique. This method requires little more skill in aligning the

probe with needle path and longitudinal cut section of the vein as the working space available

is very less in the sonographic view and further this technique also needs to be studied in all

group of patients to see its feasibility.

Conclusion:

With this open-door technique, we will be able to cannulate the SCV easily with this simple

scanning method and further puncture point taken are as close to the clavicle as possible

having resemblance to Landmark technique without any major complications.

 PICTURES:
FIGURE 9: FIGURE 10:
FIGURE 2: FIGURE 1:

FIGURE 3: FIGURE 4:

FIGURE 5: FIGURE 6:

FIGURE 7: FIGURE 8:
FIGURE 11: FIGURE 12:

FIGURE 13: FIGURE 14:

FIGURE 15: FIGURE 16: