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LETTERS TO EDITOR
Year : 2021  |  Volume : 15  |  Issue : 2  |  Page : 245-247

Difficult central venous catheter insertion via the right subclavian vein


Department of Anesthesia, Ube Industries Central Hospital, Ube Yamaguchi, Japan

Correspondence Address:
Yasuhiro Morimoto
750 Nishikiwa Ube Yamaguchi, 755-0151
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_962_20

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Date of Submission20-Sep-2020
Date of Acceptance20-Sep-2020
Date of Web Publication01-Apr-2021
 


How to cite this article:
Morimoto Y, Yoshimura M. Difficult central venous catheter insertion via the right subclavian vein. Saudi J Anaesth 2021;15:245-7

How to cite this URL:
Morimoto Y, Yoshimura M. Difficult central venous catheter insertion via the right subclavian vein. Saudi J Anaesth [serial online] 2021 [cited 2021 Apr 21];15:245-7. Available from: https://www.saudija.org/text.asp?2021/15/2/245/312975



Sir,

Ultrasound-guided central venous catheter insertion has improved the success rates and safety associated with the procedure.[1] However, owing to the limitations of ultrasonographic evaluation, unanticipated anatomical abnormalities might result in unsuccessful central venous catheter insertion. We report a case of technically challenging central venous catheter insertion via the right subclavian vein owing to an anatomical abnormality of this vessel.

A 63-year-old man with a history of lung cancer was scheduled to undergo central venous catheter port placement for chemotherapy. We performed ultrasound-guided venous puncture via the right subclavian vein, and the guidewire was easily inserted; however, we encountered resistance after the guidewire was advanced over approximately 20 cm. X-ray fluoroscopy confirmed that the guidewire could not be advanced, and it turned cephalad at the level of the clavicle and was directed toward the heart which indicate the abnormal venous anatomy [Figure 1]. We aborted the puncture considering a possible right subclavian vein abnormality. A review of the patient's medical history revealed that he underwent metastatic brain tumor removal surgery under general anesthesia, a month prior to presentation. Right subclavian venipuncture was attempted at that time; however, the procedure was unsuccessful, and the central venous catheter had to be inserted via the left internal jugular vein. We performed contrast-enhanced computed tomography to diagnose vascular abnormalities, we observed severe stenosis of the right subclavian vein below the clavicle, and this vessel ran as a small vein lateral to the trachea before it joined the superior vena cava [Figure 2]. Therefore, we concluded that the right subclavian vein was obstructed in the vicinity of the clavicle and was perfused via collateral circulation. The left subclavian vein appeared normal; therefore, we successfully inserted the catheter via the left subclavian vein on the other day.
Figure 1: X-ray fluoroscopy view during the procedure

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Figure 2: Contrast-enhanced computed tomography to diagnose the subclavian vein anatomy. SCV: Subclavian vein (a) around the clavicle (b) around the cervical region

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In this case, ultrasound-guided venous puncture could be easily performed. However, ultrasonographic evaluation is associated with some limitations, and visualization of the anatomy below the clavicle and in the more proximal aspects, including in the vicinity of the inferior vena cava may be difficult when inserting a guidewire and catheter via the subclavian vein.[2]

Non-advancement of the guidewire proximally could be attributed to its passage into small vein branches, coiling, anatomical variations, and vein stenosis. Any resistance to guidewire and catheter insertion might cause serious complications, including vein perforation.[3] In this case, the anatomical abnormality of the right subclavian vein was confirmed by intraoperative fluoroscopy, followed by contrast-enhanced computed tomography. Therefore, we selected a different insertion site.

We should be aware of the possibility of anatomical abnormalities, which might complicate central venous catheter insertion. Fluoroscopy should be performed to confirm anatomical abnormalities in patients in whom resistance is encountered during guidewire and catheter insertion. In conclusion, ultrasonography combined with fluoroscopy can aid in safe central venous catheter insertion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Airapetian N, Maizel J, Langelle F, Modeliar SS, Karakitsos D, Dupont H, et al. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. Intensive Care Med 2013;39:1938-44.  Back to cited text no. 1
    
2.
Bodenham AR. Ultrasound-guided venous access. In: Hamilton H, Bodenham AR, editors. Central venous catheters. Chichester: Joh Wiley and Sons Ltd; 2009, pp. 127-41.  Back to cited text no. 2
    
3.
Hartly-Jones C. Problems and practical solutions during insertion of catheters. Central venous catheters. Chichester: Joh Wiley and Sons Ltd; 2009. pp. 157-74.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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