Recommendations for Placing a Central Venous Line (CVL) in the Brachiocephalic Vein
Ultrasound-guided supraclavicular cannulation of the brachiocephalic vein is a safe and effective approach for central venous access that may reduce catheter-related complications compared to other sites. 1
Indications and Advantages
- The brachiocephalic (innominate) vein is an appropriate site for central venous access and has been made more accessible through ultrasound guidance 1
- This approach may be associated with a lower risk of contamination compared to sites in the groin (femoral vein), neck (high approaches to internal jugular vein), or antecubital fossa 1
- Brachiocephalic vein access via supraclavicular approach may decrease catheter maintenance-related complications including central line-associated bloodstream infections (CLABSI) and deep vein thrombosis 2
Technical Approach
- Real-time ultrasound guidance is strongly recommended for all brachiocephalic vein cannulations to reduce complications and increase success rates 1
- Use a supraclavicular approach to access the brachiocephalic vein, which allows for better visualization and safer insertion 2, 3
- Follow these key steps for ultrasound-guided insertion:
- Identify the anatomy of the insertion site using both short-axis (transverse) and long-axis (longitudinal) views 1
- Position the patient appropriately - consider Trendelenburg position to increase venous filling 1
- Confirm needle position in the vein using ultrasound before advancing the guidewire 1
- Verify correct guidewire and catheter position in the vein using ultrasound 1
Catheter Tip Positioning
- The tip of the 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
- Confirm the position of the catheter tip during the procedure, especially when using the brachiocephalic approach 1
- Post-procedure X-ray is mandatory when the position of the tip has not been checked during the procedure 1
Infection Prevention Measures
- Use maximal sterile barrier precautions during insertion, including cap, mask, sterile gown, sterile gloves, and a sterile full-body drape 1
- Prepare the skin with 2% chlorhexidine gluconate in 70% isopropyl alcohol as the preferred antiseptic 1
- Allow the antiseptic to air dry completely before insertion 1
- Cover the catheter exit site with a sterile, transparent, semi-permeable polyurethane dressing, which should be changed every 7 days 1
Potential Complications and Precautions
- Be aware of the risk of brachiocephalic vein perforation, especially when inserting from the left side 4
- Avoid excessive force when advancing catheters or guidewires to prevent "tenting" of the vein wall 4
- Monitor for complications such as pneumothorax, arterial puncture, and catheter malposition, although these may be less common with ultrasound guidance 2, 5
- Be vigilant for air embolism, which can occur during insertion if proper technique is not followed 6
Special Considerations
- The brachiocephalic vein approach has shown promising results in pediatric populations, with lower rates of complications compared to other sites 2, 3, 5
- For patients with advanced kidney disease or those on hemodialysis, the brachiocephalic vein may be preferable to the subclavian site, which should be avoided in these populations 1, 7
- Avoid the femoral site when possible due to higher risk of infection and thrombosis 1
Contraindications
- Infection at the insertion site is an absolute contraindication 7
- Distorted anatomy that prevents clear identification of anatomical landmarks 7
- Known venous thrombosis or stenosis at the proposed insertion site 7
- Vascular injury at the proposed insertion site 7
By following these recommendations, the brachiocephalic vein can be safely accessed for central venous catheterization with potentially lower complication rates than traditional approaches.