What are the best veins for difficult peripheral intravenous (IV) access?

Best Veins for Difficult Peripheral IV Access

For difficult peripheral IV access, ultrasound-guided cannulation of the basilic vein is the preferred first choice, followed by the brachial vein, while the cephalic vein should be avoided due to higher thrombosis rates and technical difficulties. 1

Upper Extremity Vein Selection Hierarchy

First Choice: Basilic Vein

• The basilic vein is the access vein of choice because it is superficial and is usually the largest vein in the arm 1
• This vein provides optimal success rates when accessed with ultrasound guidance 1
• Its superficial location and larger diameter make it technically easier to cannulate in difficult access situations 1

Second Choice: Brachial Vein

• The brachial vein can be used when the basilic vein is unavailable 1
• Important caveat: Brachial vein access carries a greater risk of injury to the brachial artery and median nerve 1
• This site requires more careful technique and anatomical awareness 1

Avoid: Cephalic Vein

• Access via the cephalic vein has a higher incidence of thrombosis due to its smaller size 1
• The catheter is susceptible to movement and kinking as it overlies the biceps muscle 1
• This vein should be reserved only when other options are exhausted 1

Alternative Approaches for Difficult Access

Ultrasound-Guided Peripheral Internal Jugular

• For patients with failed traditional peripheral IV attempts, ultrasound-guided peripheral catheter placement in the internal jugular vein achieves 90-97% first-attempt success rates 2, 3
• This technique uses a standard 2.5-inch, 18-gauge peripheral catheter placed in the IJ under ultrasound guidance 4, 3
• Mean procedural time is approximately 3-5 minutes 4, 3
• Complication rates are low (2.9%), with no arterial punctures or pneumothoraces reported in recent studies 3
• This approach is particularly useful for short-term access when central lines are not indicated 4

Midline Catheters

• Midline catheters (10-20 cm length) inserted into upper arm veins with ultrasound guidance are appropriate when expected duration of use is 6-14 days 1
• These should be placed in the basilic or brachial veins using the same hierarchy as standard peripheral access 1
• Midline catheters are preferred over PICCs for difficult access when duration is ≤14 days 1

Deep Antecubital Veins

• Ultrasound guidance can be used for deeper, non-visible veins in the antecubital fossa 1
• Blind deep antecubital fossa puncture should be abandoned 1
• A gel standoff device may help visualize superficial veins that are compressed by the probe 1

Essential Technical Considerations

Ultrasound Guidance is Mandatory

• Transillumination, ultrasound, and infrared devices may be useful for difficult peripheral access 1
• Ultrasound-guided peripheral access in DIVA (difficult intravenous access) patients improves first-time success rate from 18% to 90% 2
• The overall success rate increases from 46% to 95% with ultrasound guidance 2
• Mean procedural time decreases significantly (2.7 minutes vs 10 minutes) with ultrasound 2

Catheter Selection

• The smallest practical size of cannula should be used 1
• For peripheral IJ access, an 18-gauge, 2.5-inch catheter is standard 4, 3
• In pediatric patients, the external diameter of the catheter should not exceed 1/3 of the internal diameter of the vein to avoid thrombosis 1

Critical Pitfalls to Avoid

Anatomical Contraindications

• Insertion in a limb with lymphedema should be avoided except in acute situations due to increased infection risk 1
• In patients with stage 3b CKD or greater (eGFR <45 mL/min), avoid devices in arm veins to preserve vessels for future hemodialysis access 1
• For CKD patients requiring short-term access, use peripheral IVs in the dorsum of the hand, avoiding forearm veins 1

Duration-Based Decision Making

• Routine changes of peripheral cannulae at 72-96 hours is not advocated 1
• For access expected to last >14 days, consider PICC or tunneled catheter rather than repeated peripheral attempts 1
• All cannulae must be flushed after use to maintain patency 1

When to Escalate

• If ultrasound-guided peripheral access fails after 2-3 attempts, consider peripheral IJ or central access rather than continued peripheral attempts 2, 3
• Intraosseous access is faster than central access in emergencies when IV access is difficult 1