Subclavian CVCs

ProceduresResuscitation
Written By Dillon Warr

Hey Team, 


Let’s talk subclavian vein cannulation:

Why subclavian?

  • Lower infection and thrombosis risk than femoral and often IJ

  • Preserves patient neck mobility and may be more comfortable for the patient.

  • Good for trauma patients who have C-spine immobilization in place.

  • Might be the best option during a trauma with concern for IVC injury (eg. abdominal GSW).

Landmark-Guided Infraclavicular Approach

Some Videos for Reference:

What you are targeting

  • The subclavian vein as it courses over the first rib, immediately posterior to the clavicle

Setup

  • Supine, Trendelenburg if tolerated

  • Neutral shoulders. Aggressive shoulder retraction can narrow the costoclavicular space and collapse the vein

  • Remember to return arm to the side after a tube or finger thoracostomy

Needle mechanics

  • Insert just inferior to the clavicle near the medial–middle third junction

  • The needle is directed medially toward the index fingertip of the non-dominant hand which is placed in the suprasternal notch.  

  • Use the clavicle as your “roof” and keep the needle flat

  • Avoid steep caudal angles that dive toward pleura

  • Standard Seldinger once venous blood is obtained

Strengths

  • Fast, no ultrasound dependency

  • Anatomy of subclavian is predictable

  • Familiar to experienced operators

  • Works when ultrasound access or sterility logistics are limiting

Limitations

  • Blind to artery and pleura

  • Higher mechanical complication risk in inexperienced hands

Ultrasound-Guided Approaches

Ultrasound Guided Infraclavicular (More honestly a distal subclavian/axillary approach)

What you are actually targeting

  • Usually the distal subclavian or axillary vein, not the classic medial subclavian

Setup

  • Probe inferior and lateral to the clavicle

  • Identify vein, artery, and pleura before needle entry

Needle mechanics

  • In-plane, long-axis preferred to continuously track the needle tip

  • Shallow approach with deliberate advancement

  • Visualize the wire in the vessel before dilation

Strengths

  • Lower complication rates when done well

  • Real-time visualization of pleura and artery

Limitations

  • Clavicle shadow limits access to more medial targets

  • Technically demanding scan for novices

Ultrasound-Guided Supraclavicular Approach

What you are targeting

  • The subclavian vein at or just distal to its confluence with the IJ

Setup

  • Operator at the head of the bed, similar to IJ positioning

  • Probe placed above the clavicle in the supraclavicular fossa

  • Follow the IJ caudally until it joins the subclavian

Needle mechanics

  • Typically long-axis guidance

  • Needle enters from lateral to medial under direct visualization

  • First rib is often visible deep to the vein, acting as a safety backstop

  • Standard Seldinger technique after venous access

Strengths

  • Often superior visualization of vein, artery, and pleura in one window

  • More controlled needle trajectory for some operators

  • Avoids clavicle shadowing seen infraclavicularly

  • Can be ergonomically easier in crowded resuscitation bays

Limitations

  • Less commonly taught, fewer operators are comfortable

  • Tight anatomy may require smaller or endocavitary probes

  • Not ideal with significant supraclavicular hematoma or local trauma

Why go landmark guided when we have US?

  • No ultrasound available or sterile setup would delay care

  • Operator proficiency favors landmark technique

  • Ultrasound window is poor due to anatomy or positioning

  • Ultrasound in use elsewhere during active resuscitation

Bottom line

  • Ultrasound guidance reduces complications when anatomy is visualized and the operator is practiced

  • Landmark subclavian remains a legitimate, sometimes optimal choice

  • Supraclavicular ultrasound is an underused but elegant option worth having in your toolbox

References and Things You Should Check Out:

Dillon Warr
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