What is the preferred approach for subclavian central line placement, supraclavicular or infraclavicular?

Supraclavicular vs Infraclavicular Approach for Subclavian Central Line Placement

The supraclavicular approach is superior to the infraclavicular approach for subclavian central line placement due to better ultrasound visualization, lower complication rates, and shorter procedural times. 1, 2

Ultrasound Visualization Advantages

• The supraclavicular approach offers perfect in-plane needle visualization that is not interrupted by bony structures, while the infraclavicular approach requires dealing with acoustic shadowing from the clavicle 3
• Ultrasound studies show significantly better visualization of the subclavian vein with the supraclavicular approach compared to the infraclavicular approach (mean Likert score 3.94 vs 3.10) 4
• The supraclavicular approach allows visualization of the distal end of the subclavian and brachiocephalic veins 3

Complication Rates

• The supraclavicular approach has significantly fewer catheterization-related complications compared to the infraclavicular approach (3.0% vs 13.4%) 1
• Catheter misplacement is significantly less common with the supraclavicular approach 1
• The infraclavicular approach carries higher risks of pneumothorax, catheter fatigue, "pinch-off syndrome," and potential catheter fracture 5, 6

Procedural Efficiency

• Total procedural time is significantly shorter with the supraclavicular approach compared to the infraclavicular approach 2
• Time for visualization, puncture, and catheterization are all significantly lower with the supraclavicular approach 2
• First-attempt success rates tend to be higher with the supraclavicular approach 2

Anatomical Considerations

• The subclavian vein lies anterior and inferior to the subclavian artery, with the pleural space in close proximity posteriorly 5
• In the supraclavicular approach, the vein is closer to the skin and farther from the pleural dome, providing an anatomical advantage 7
• Special care should be given to visualizing and avoiding the brachial plexus when using the supraclavicular approach, particularly in small children and neonates 3

Practical Implementation

• Ultrasound guidance is strongly recommended for all central venous catheter insertions regardless of approach 3, 5, 6
• The Trendelenburg position helps distend the vein, increasing its cross-sectional area and improving the likelihood of successful cannulation 5
• For either approach, the tip of the 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 3, 5
• Post-procedure chest X-ray is mandatory when the position of the catheter tip has not been checked during the procedure or when using a blind subclavian approach 3, 5

Special Populations

• In hemodialysis patients and those with advanced kidney disease, the subclavian site should be avoided altogether to prevent subclavian vein stenosis 6
• For patients with tracheostomy or severe anatomical abnormalities of the neck and thorax, alternative access sites should be considered 6
• In neonates and children, ultrasound guidance should be routinely used for central venous access, with the supraclavicular route requiring experienced operators 3