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Year : 2023  |  Volume : 17  |  Issue : 1  |  Page : 131-132

Left brachiocephalic vein is a novel site for ultrasound-guided central venous catheterization in the prone position

Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India

Correspondence Address:
Amarjeet Kumar
Room No 505, B-Block, OT Complex, All India Institute of Medical Sciences, Patna - 801 507, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.sja_465_22

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Date of Submission24-Jun-2022
Date of Decision26-Jun-2022
Date of Acceptance28-Jun-2022
Date of Web Publication02-Jan-2023

How to cite this article:
Kumar A. Left brachiocephalic vein is a novel site for ultrasound-guided central venous catheterization in the prone position. Saudi J Anaesth 2023;17:131-2

How to cite this URL:
Kumar A. Left brachiocephalic vein is a novel site for ultrasound-guided central venous catheterization in the prone position. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 31];17:131-2. Available from:

To the editor,

Central venous catheterization (CVC) is an essential part of clinical management in major surgeries. Unusual patient position (prone or lateral) poses anesthesiologist challenges during CVC insertion.[1] Several different major vessel sites like the internal jugular vein (IJV) and popliteal vein have been explored for CVC cannulation during the prone position.[1],[2],[3] The objective of this report is to describe a novel approach for ultrasound (US)-guided CVC insertion; the left brachiocephalic vein (BCV) cannulation in the prone position. Written and informed consent for publication was taken from the patient.

A 28-year-old male patient, having C5–C6 subluxation was scheduled for posterior decompression with lateral mass screw fixation. The patient received general anesthesia with two large-bore peripheral lines and an arterial line. After induction of anesthesia, the patient was positioned prone using a horseshoe headrest with a cervical tong for skull traction. During patient positioning, there occurred accidental removal of one peripheral line and one episode of hypotension. The anesthesia plan was changed to go with CVC insertion. US-guided left BCV cannulation was done in the prone position. For this, we placed the linear US probe (M-Turbo, Fujifilm Sonosite, Inc., Bothell, WA, USA) in the left supraclavicular fossa parallel to the medial end of the clavicle with the patient in the prone position. The probe was tilted caudally to identify the venous confluence of “Pirogoff” [subclavian vein (SCV), IJV, and BCV] [Figure 1]. Doppler power was used to differentiate the subclavian and the other arteries from the vein. The puncture needle was inserted in-plane to the US probe from lateral to medial direction. The CVC was inserted into the left BCV using the Seldinger technique.
Figure 1: Panel a: needle probe position in the prone patient, Panel b: sonoanatomy of the left brachiocephalic vein, (BCV: brachiocephalic vein, IJV: internal jugular vein, SCV: subclavian vein, blue arrow: needle trajectory), Panel c: In-plane view of the guide wire in BCV, Panel d: chest X-ray confirming CVC position

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The prone position provides an optimal surgical field for spine surgery; however, this patient position eliminates access to the femoral and SCV for CVC insertion. Chen et al.[1] attempted for US-guided CVC insertion in the right IJV in a prone patient by using the out-plane needle technique. However, they failed to cannulate right IJV because the technique needed the left hand to hold the introducer needle. Adams et al.[3] inserted a dialysis catheter in the left popliteal vein for renal replacement therapy in COVID-19 patients on mechanical ventilation in the prone position. However, popliteal vessels used for CVC insertion have certain limitations like the requirement of a highly experienced anesthesiologist who is familiar with the sonoanatomy of the popliteal fossa, increased risk of provoking lower extremity deep venous thrombosis[3], and poor catheter tolerance by the patient.

In this case, we have successfully placed the CVC into the left BCV and its tip position was confirmed by a chest X-ray after making the patient supine as shown in [Figure 1] (panel D). Left BCV was chosen over right because of its horizontal course. Some additional challenges faced during the US-guided CVC insertion in the prone position include loss of probe attachment to the skin surface at the time of needle insertion, poor US-probe needle alignment, difficult to maintain aseptic needle puncture site, and difficulty during fixation of CVC catheter.


Taken from patient.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chen GY, Cheng KI, Hsu HT, Lu YM. Ultrasound-guided central venous catheterization in the prone position. Br J Anaesth 2017;119:337-8.  Back to cited text no. 1
Sofi K, Arab S. Ultrasound-guided central venous catheterization in prone position. Saudi J Anaesth 2010;4:28-30.  Back to cited text no. 2
[PUBMED]  [Full text]  
Adams E, Mousa AY. Achieving a popliteal venous access for renal replacement therapy in critically ill COVID-19 patient in prone position. J Vasc Surg Cases Innov Tech 2020;6:266-8.  Back to cited text no. 3


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