LETTERS TO EDITOR
Year : 2021 | Volume
| Issue : 2 | Page : 245-247
Difficult central venous catheter insertion via the right subclavian vein
Yasuhiro Morimoto, Manabu Yoshimura
Department of Anesthesia, Ube Industries Central Hospital, Ube Yamaguchi, Japan
750 Nishikiwa Ube Yamaguchi, 755-0151
Source of Support: None, Conflict of Interest: None
|Date of Submission||20-Sep-2020|
|Date of Acceptance||20-Sep-2020|
|Date of Web Publication||01-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
Ultrasound-guided central venous catheter insertion has improved the success rates and safety associated with the procedure. 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 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.
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. 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.
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Conflicts of interest
There are no conflicts of interest.
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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.
Hartly-Jones C. Problems and practical solutions during insertion of catheters. Central venous catheters. Chichester: Joh Wiley and Sons Ltd; 2009. pp. 157-74.
[Figure 1], [Figure 2]
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