Anatomic basis of safe percutaneous subclavian venous catheterization

Background: The technique of percutaneous catheterization of the subclavian vein by the infraclavicular approach is dependent on the location of the subclavian vein in relation to the clavicle, The purpose of this study was to analyze the anatomic relationship between these two structures and how it is influenced by changes in shoulder positioning. Methods: Dissections of the infraclavicular region were performed in seven fresh cadavers and linear measurements made to determine the extent of overlap between the vein and the clavicle in different shoulder positions. Results: When the shoulder was in neutral position, the subclavian vein was overlapped by the medial third or more of the clavicle and this segment of bone was able to serve as a land-mark For the vein, However, shoulder elevation displaced the clavicle cephalad and reduced the degree of overlap, Mild shoulder retraction increased the area of contact between the vein and the undersurface of the clavicle, whereas protraction lifted the clavicle off the vein. Conclusion: Infraclavicular subclavian venipuncture should be performed with shoulders in a neutral position and also in slight retraction. An appreciation of the anatomic relationship between the clavicle and the subclavian vein is the key to successful execution of this technique.