Is a subclavian vein approach with a puncture inferior to the clavicle and tunneling inferiorly near the upper breast suitable for this patient?

Subclavian Vein Approach for Central Venous Access

For this patient, a subclavian vein approach with puncture inferior to the clavicle and tunneling inferiorly near the upper breast should be avoided due to higher risk of mechanical complications and potential "pinch-off syndrome" that can lead to catheter damage and embolization. 1

Preferred Central Venous Access Sites

Right Internal Jugular Vein as First Choice

• The right internal jugular vein is the preferred access site for central venous catheterization because it has a more direct trajectory to the cavo-atrial junction and is associated with lower risk of complications compared to other insertion sites 1
• The internal jugular approach carries less risk of insertion-related complications compared to the subclavian vein 1
• The low lateral approach to the internal jugular vein (Jernigan's approach) appears to be the technique associated with the lowest risk of mechanical complications 1

Subclavian Vein Considerations

• While the CDC 2011 guidelines recommend the subclavian site over jugular or femoral sites for non-tunneled CVCs to reduce infection risk, this must be balanced against other complications 1
• The subclavian approach carries higher risks of:
  • Pneumothorax 1, 2
  • Catheter fatigue and "pinch-off syndrome" due to compression between the clavicle and first rib 1, 3
  • Potential catheter fracture with embolization into the pulmonary vascular bed 1
  • Higher mechanical complication rates, particularly with right-sided attempts (35.5% vs 12.5% for left-sided attempts) 2

Tunneling Considerations

• Tunneling a catheter inferiorly near the upper breast from a subclavian puncture increases the risk of "pinch-off syndrome" 1
• The pinch-off syndrome is a compression of a large bore silicone catheter between the clavicle and the first rib, typically secondary to 'blind' percutaneous placement in the subclavian vein via the infraclavicular route 1
• This compression may lead to malfunction, obstruction, damage and even fracture of the catheter, with embolization of catheter fragments 1, 3

Ultrasound Guidance Recommendation

• Ultrasound-guided venepuncture is strongly recommended for all CVC insertions as it is associated with lower incidence of complications and higher success rates than 'blind' venepuncture 1
• Real-time ultrasound guidance allows for more precise vessel location and may indirectly reduce the risk of contamination and infection 1
• Ultrasound guidance should only be used by those fully trained in its technique 1

Catheter Tip Positioning

• The tip of a central venous catheter should be positioned in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium 1
• Proper tip positioning helps reduce the risk of complications such as thrombosis, erosion, and pericardial tamponade 1
• The position of the tip should be checked during the procedure, especially when an infraclavicular approach to the subclavian vein has been used 1

Alternative Approaches to Consider

• If subclavian access is necessary, consider:
  • The supraclavicular approach to the subclavian vein, which has been reported to have fewer complications than the infraclavicular approach 4, 5
  • Left-sided subclavian attempts which appear to have lower complication rates than right-sided attempts 2
• For patients requiring long-term access, a peripherally inserted central catheter (PICC) may be considered if the duration of IV therapy will likely exceed six days 1

Special Considerations for Specific Patient Populations

• In hemodialysis patients and those with advanced kidney disease, avoid the subclavian site to prevent subclavian vein stenosis 1
• For patients with tracheostomy or severe anatomical abnormalities of the neck and thorax, peripheral venous access (PICC) may be preferable 1
• In patients at high risk for infection, the subclavian site may be preferred over jugular or femoral sites 1, 6

By following these evidence-based recommendations, the risk of mechanical, infectious, and thrombotic complications can be minimized while ensuring effective central venous access for the patient.