Revisiting Ultrasound-Guided Subclavian/Axillary Vein Cannulations: Importance of Pleural Avoidance With Rib Trajectory

J Intensive Care Med. 2017 Jul;32(6):396-399. doi: 10.1177/0885066617701413. Epub 2017 Mar 30.


The Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections suggest using "a subclavian site, rather than an internal jugular or a femoral site, in adult patients." This recommendation is based on evidence of lower rates of thrombosis and catheter-related bloodstream infections in patients with subclavian central venous catheters (CVCs) compared to femoral or internal jugular sites. However, preference toward a subclavian approach to CVC insertion is hindered by increased risk of mechanical complications, especially pneumothorax, when compared to other sites. This is largely related to the proximity of the subclavian vein to the pleural space and the traditional "blind" or anatomic landmark approach used in subclavian vein cannulation. We revisit a method that may provide increased safety and avoidance of pneumothorax during ultrasound-guided subclavian/axillary vein cannulation. This is achieved by directing the needle toward the subclavian vein at a point where it traverses over the second rib, providing a protective rib shield between the vessel and pleura as a safety net for operators. The technique also allows for increased compressibility of the subclavian/axillary vein in the event of bleeding complication.

Keywords: central venous catheter; subclavian; ultrasound.

Publication types

  • Guideline

MeSH terms

  • Axillary Vein / diagnostic imaging*
  • Catheter-Related Infections / prevention & control*
  • Catheterization, Central Venous / adverse effects
  • Catheterization, Central Venous / methods*
  • Centers for Disease Control and Prevention, U.S.
  • Critical Care*
  • Critical Illness / therapy*
  • Humans
  • Pleural Diseases / prevention & control
  • Punctures / adverse effects
  • Ribs* / diagnostic imaging
  • Sepsis / prevention & control
  • Subclavian Vein / diagnostic imaging*
  • Ultrasonography, Interventional*
  • United States