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Table of Contents
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 5-9

Supraclavicular versus Infraclavicular Subclavian Vein Catheterization in Coronary Artery Bypass Graft Surgery

1 Department of Anesthesiology, Clinical Research Development Unit of Farshchian Hospital, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
2 Department of Biostatistics, Modeling of Noncommunicable Diseases Research Center, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran

Date of Web Publication26-Feb-2018

Correspondence Address:
Dr. Maryam Davoudi
Department of Anesthesiology, Clinical Research Development Unit of Farshchian Hospital, School of Medicine, Hamadan University of Medical Sciences, Hamadan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_26_17

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Background: Percutaneous central vein catheterization is one of the most invasive procedures commonly performed by anesthesiologists during cardiac surgery. Objectives: The aim of this study was to investigate the complications of supraclavicular (SC) versus infraclavicular (IC) approaches for subclavian vein catheterization during coronary artery bypass graft surgery. Materials and Methods: Between October 2014 and June 2015, this prospective, randomized clinical trial was performed in 280 patients. The patients were randomly cannulated by SC or IC approach. The success and complication rates were compared for the two approaches. The outcome of this study was analyzed using SPSS software and through Chi-square test. Results: In the first attempt of catheterization, the success rate in SC (78.6%) group was lower than IC (94.3%) group (P = 0.0001). The overall success rate in two attempts were 136 (97.1%) in the IC approach and 132 (94.3%) in the SC approach (P = 0.238). In 12 (4.3%) patients, subclavian catheterizations were failed after two attempts in both approaches. In 28 (10%) patients, hematoma at puncture site occurred, 1 (0.7%) in IC approach, and 27 (19.3%) in SC approach (P = 0.0001). The differences in other complications on two approaches were statistically insignificant. Conclusions: Compared with the SC approach, the IC approach resulted in fewer hematomas at puncture sites. The incidence of overall cannulation failure and other complications were similar on both approaches.

Keywords: Catheterization, complications, coronary artery bypass, subclavian vein

How to cite this article:
Tarbiat M, Farhanchi A, Davoudi M, Farhadian M. Supraclavicular versus Infraclavicular Subclavian Vein Catheterization in Coronary Artery Bypass Graft Surgery. Res Cardiovasc Med 2018;7:5-9

How to cite this URL:
Tarbiat M, Farhanchi A, Davoudi M, Farhadian M. Supraclavicular versus Infraclavicular Subclavian Vein Catheterization in Coronary Artery Bypass Graft Surgery. Res Cardiovasc Med [serial online] 2018 [cited 2023 Mar 27];7:5-9. Available from: https://www.rcvmonline.com/text.asp?2018/7/1/5/226163

  Introduction Top

Percutaneous central vein catheterization is one of the most invasive procedures commonly performed by anesthesiologists during cardiac surgery. It is a routine procedure during cardiac surgery for monitoring central venous pressure, prescription of medications, rapid infusion of fluids (through large cannulas), cardiopulmonary resuscitation, insertion of a transvenous pacemaker, and difficult peripheral catheterization.[1],[2] Advantages of subclavian venous cannulation in comparison with internal jugular and femoral approaches include a lower risk of infection and increased patient comfort, especially for long-term intravenous therapy. Two main approaches may be preferred for cannulation: infraclavicular (IC) and supraclavicular (SC) subclavian vein cannulation, which latter, for uncertain reasons, is seldom used. The subclavian vein catheterizations through an IC and SC approach were carried out for the first time by Aubaniac in 1952 and Yoffa in 1965, respectively.[3] Percutaneous subclavian vein catheterization often is a blind method and requires localization of a deep vein by applying superficial anatomical landmarks. Thus, the procedure frequently requires multiple needle attempts. Most of the physicians who accomplish central catheterization are entirely unfamiliar with the SC cannulation when compared with the other approaches; nevertheless, several advantages were reported for this approach in previous studies may help physicians overcome this unfamiliarity during subclavian vein catheterization. These advantages are a vast target region for the insertion of the needle, a straighter path to the superior vena cava, a shorter distance from skin to vein, less proximity to the lung, easy accessibility, higher success rate and a more reliable, and constant surface landmark.[3],[4],[5],[6]

Although some of the physicians believe that internal jugular vein is choice for catheterization in cardiac surgery due to a high success rate of cannulation and a lower risk of pneumothorax when compared with subclavian vein cannulation, but accidental carotid artery puncture during internal jugular vein cannulation may result in serious neurologic sequelae in these high-risk atherosclerotic patients who frequently have carotid artery atherosclerosis. In cardiac patients who often have to preserve a catheter in their neck for more than a week, Patient's comfort is a significant issue throughout this time.[4]

Therefore, in our center for patient comfort, ease of neck motion and better nursing care, subclavian vein catheterization is preferred.


The aim of this study was to investigate the complications of SC versus IC approaches for subclavian vein catheterization during coronary artery bypass graft (CABG) surgery.

  Materials and Methods Top

This study was a randomized clinical trial that was performed between October 2014 and June 2015 after approval from the ethics committee. Written informed consent was obtained from all the patients before the study. This study also was registered in Iranian Registry of Clinical Trials (IRCT2014102210348N3). Two hundred and eighty patients of the American Society of Anesthesiologists physical status II-III, aged between 25 and 85 years scheduled to undergo CABG surgeries were enrolled for the study.

The patients were randomly assigned to one of the two arms (IC or SC approach for catheterization) of the trial using block randomization method (size of block = 4, list made up of 70 blocks of four allocations, with two treatment and two control allocations randomly ordered within each block). The flow diagram presented in [Figure 1]. The allocation was concealed with numbered, sealed, and opaque envelopes containing the group allocation cards by an independent enrolling investigator. The blindness of physician was not possible; however, statistical analyzer and patients were blind because they could not distinguish between two types of method.
Figure 1: Flow diagram

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Our exclusion criteria were emergency surgery, prior radiotherapy at the attempted catheterization site, patients with musculoskeletal or congenital vascular anomaly in the neck area, regional skin infection or hematoma at puncture sites, prior pneumothorax, blood coagulopathy, concurrent carotid endarterectomy during the operation, previous catheterized or surgery in the region of subclavian vein cannulation (e.g., mastectomy, axillary node dissection, previous radical neck surgery or thoracotomy).

After induction of anesthesia and tracheal intubation, the catheterization was done in the Trendelenburg position to avoid air embolism and to distend the vein. The head of the patient was rotated slightly to the contralateral side, and the arm was placed on the side. The cannulations were undertaken by right-handed experienced cardiovascular anesthesiologists.

An 18 gauge needle was used on a 5 ml syringe, aspirating as the needle was advanced. For infraclavicular approach, puncture site was 1 cm beneath the clavicle at the junction of middle and medial thirds of the clavicle and directing the needle toward the supra-sternal notch. For SC approach, the needle was inserted 1 cm above and 1 cm lateral to the junction of the lateral border of the clavicular head of the sternocleidomastoid muscle with the superior margin of the clavicle (claviculo-sternocleidomastoid angle). The needle was directed along the line that bisects the claviculo-sternocleidomastoid angle with elevation 5°–15° above the coronal plane. After puncture of the subclavian vein, the catheterization was done by the modified Seldinger technique. The modified Seldinger technique was used for both catheterization methods.

The depth of catheter (7 fr, Tri-lumen arrow central catheter; 20 cm) insertion was 15 cm for infraclavicular or SC catheterization. After successful insertion, all 3 lumens were checked for blood aspiration, and if aspiration was unsuccessful, the catheter was pulled back slowly to the point that allows free blood aspiration and fixed at that level. If the assigned approach was unsuccessful after two attempts at catheterization, the right internal jugular vein was used for catheterization. Each skin puncture was defined as an attempt. It should be noticed that in the SC approach, the dilator was never inserted more than 2 cm.

Chest radiographs were obtained in the intensive care unit immediately after the surgery to determine the complications and position of the catheter tip.

Procedures were monitored for arterial puncture and accurate recording of the number of passes. Pneumothorax was treated with anterior intercostals underwater seal drains when necessary, and subclavian arterial punctures were treated with 5 min of digital pressure over the insertion site after removal of the needle.

Variables study: age, gender, weight, height, body mass index, the number of needle passes (defined as separate skin punctures) attempted, success rate at the selected approach, and probable complications such as malposition of catheter tip, pneumothorax, hemothorax, subclavian arterial puncture, hematoma at puncture site, and thoracic duct damage. Routine assessment before subclavian vein cannulation included a chest X-ray, platelet count, prothrombin time (PT), and partial thromboplastin time (PTT).

Calculation of sample size was based on similar study and assuming catheter tip misplacement in IC and SC groups were 12% and 2%, respectively, with a two-sided significance of 0.05 and a power of 0.9, a total of 132 × 2 = 264 patients will be required. However, we decided to enroll 140 patients in each group.


Kolmogorov–Smirnov normality test showed the normality of continues data. The Chi-square test was used to evaluate the relationship between catheterization procedures success rate and the cannulation approach in two groups. Furthermore, t-test was carried out to for evaluation of the differences between means of continues variable between two groups. The P < 0.05 indicated statistical significance. All statistical calculations were performed using SPSS (SPSS IBM, Chicago, IL, USA) version 16 software.

  Results Top

A total of 280 CABG surgery patients were enrolled in this study. The patients' characteristics are shown in [Table 1]. They were separated into two equal groups. The right subclavian veins of each group of patients (n = 140) were cannulated by SC approach or IC approach.
Table 1: Patient characteristics

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In 242 (86.4%) patients, the first attempt at subclavian catheterization was successful, 132 (94.3%) in IC approach and 110 (78.6%) in SC approach. In the first attempt of catheterization, the success rate had a significant difference between the SC and the IC groups (P = 0.0001).

In 26 patients, the second attempt on subclavian catheterization was successful, 4 (50%) in the IC approach and 22 (73.3%) in the SC approach. The overall success rate in two attempts were 136 (97.1%) in the IC approach and 132 (94.3%) in the SC approach (P = 0.238). In 12 (4.3%) patients, subclavian catheterizations were failed after two attempts in both approaches [Table 2]. In the failed catheterizations, right internal jugular vein catheterizations were done.
Table 2: Success of catheterization

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In 10 of 280 (3 in SC approach and 7 in IC approach) catheters placed through subclavian vein were misplaced. In IC approach, six catheter tips were placed in the ipsilateral internal jugular vein and in one, the catheter tip was placed in the contralateral subclavian vein (5%), but at SC approach, two catheter tips were located in the contralateral subclavian vein and one catheter formed a loop around itself over the right subclavian vein (2.14%). The overall malposition of the catheter tip in both approaches was 3.57% [Figure 2] and [Figure 3].
Figure 2: Postoperative chest X-ray depicting right subclavian vein catheter malpositioned into contralateral subclavian vein with infraclavicular approach (arrows)

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Figure 3: Postoperative chest X-ray depicting right subclavian vein catheter formed a loop around itself over the right subclavian vein with Supraclavicular approach (arrows)

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In 4 (1.4%) patients, pneumothorax was confirmed by chest X-ray (three in SC approach and one in IC approach). Subclavian arterial puncture occurred in 12 (4.3%) patients, 4 (2.9%) in SC approach, and 8 (5.7%) in IC approach.

In 28 (10%) patients, hematoma at puncture site occurred, 1 (0.7%) in IC approach and 27 (19.3%) in SC approach. There was a significant difference between the SC and the IC groups (P = 0.0001).

There was no injury of thoracic duct or hemothorax in the subclavian venous catheterization [Table 3].
Table 3: Complications of catheterization

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  Discussion Top

The subclavian vein is being preferred for central venous catheterization due to easy insertion, greater diameter, lower complication rate, and a higher level of patient acceptance. Moreover, it has a lower risk of catheter-related infection and thrombosis than femoral or internal jugular vein cannulation.[7] The SC catheterization is usually done much less than the “traditional” IC catheterization. “Why SC approach to central venous access has not become the most common is unclear. It may be a mere accident of history or misconception that central vein catheterization access from over the clavicle might be prima facie seem more dangerous.”[8] Despite lacking randomized trials, some investigations suggest that the SC catheterization has a significant advantage to the IC catheterization. SC method possesses a straight route into superior vena cava, lower complications of plural or arterial puncture, an appropriate path to central vein during CPR without interruption of it, lower complications even in novice clinicians and less deformity even in obese patients in the right subclavian vein catheterization.[3],[7]

Kocum et al. suggested that SC method for subclavian vein approach is a suitable alternative for central venous catheterization in cardiac surgery due to high success rate, ease of placement, low rate of complications, and ability to utilization after sternal retractor expansion. They have reported a 98% success rate (1–5 attempts) for subclavian vein catheter insertion. The success rates on the first try to cannulation in the IC, and SC catheterizations were 86% and 61%, respectively. The success rate in the SC approach was statistically higher than IC approach in the first attempt.[4] In the other study, the success rates of cannulation with SC and IC approaches were 78.3% and 92.8% in the first attempt, respectively.[7] Thakur et al. also documented that overall success rate in catheterization of the right subclavian vein catheterization by using SC approach was better than subclavian vein catheterization by using IC approach. First attempt success in the SC group was 75.6% as compared with 59.25% in the IC group.[5]

Lu et al. mentioned overall success of 95.2% in the right SC and 87.5% % in the left SC approach in Pediatric Intensive Care Unit. No statistically significant differences were noted among these two groups in the success rate.[9]

In another study, the success rates of subclavian vein catheterization using real-time ultrasound-guided was 97.1%.[10]

These different results may be due to a number of patients in their study, a method of catheterization, and age of patients. In our study, overall success rate (1 or 2 attempts) was 95.7%. The success rates of cannulations in the SC and IC approaches were 78.6% and 94.3% in the first attempt, respectively. These results are in concordance with the study of Kocum et al. which reported the success rate of IC approach was significantly higher than SC approach in the first attempt of catheterizations.

Malpositioning is a well-known complication of central venous catheterization. The most common reason of primary catheter malfunction is the erroneous placement of the catheter tip. Previous publications have reported an 8.95% malposition of the catheter tip in intensive care unit, and a 5.7% overall malposition in cardiac surgery with subclavian vein cannulation.[2],[11] In Ahn et al.'s study, the incidence of catheter malpositioning was 3.9% using real-time ultrasound-guided subclavian vein catheterization in the major elective surgery.[10] Several reports have stated that the incidence of catheter malpositioning is significantly higher in the IC approach than the supraclavicular approach.[4],[12] In the present study, malposition of the catheter tip in the IC approach was not significantly more common than the SC approach.

Inadvertent puncture or catheterization of the subclavian artery is a well-described complication of the subclavian vein catheterization. On the right side, the subclavian-jugular venous junction overlies the subclavian artery, causing this vessel more susceptible to damage than it is on the left side.[2] Like previous studies, we found no significant difference between subclavian arterial puncture and approach of catheterization.[1],[13]

Hematoma at puncture site is a well-known mechanical complication of subclavian venous catheterization.[6],[8] Previous reports stated a 3.18% hematoma at puncture site in subclavian venous catheterization, and 0.0%–3.33% hematoma at the puncture site in SC approach.[3],[5] In this study, hematoma at the puncture site in SC approach was significantly more than IC approach.

It should be noted again that we never threaded the silastic dilator over the J-wire more than 2 cm in the SC approach. In all of the patients, expansion of hematoma at puncture site was stopped after threading the catheters over the J-wire into the vein despite the use of high dose of heparin (300 IU/kg).

In the present study, there was no difference in complications such as hemothorax or pneumothorax between these approaches during catheterization [Table 3].

  Conclusions Top

The result of this study suggests that SC subclavian vein approach would probably not be an appropriate alternative compared to IC subclavian approach during CABG surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Czarnik T, Gawda R, Perkowski T, Weron R. Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: Analysis of 370 attempts. Anesthesiology 2009;111:334-9.  Back to cited text no. 1
Tarbiat M, Manafi B, Davoudi M, Totonchi Z. Comparison of the complications between left side and right side subclavian vein catheter placement in patients undergoing coronary artery bypass graft surgery. J Cardiovasc Thorac Res 2014;6:147-51.  Back to cited text no. 2
Tomar GS, Chawla S, Ganguly S, Cherian G, Tiwari A. Supraclavicular approach of central venous catheter insertion in critical patients in emergency settings: Re-visited. Indian J Crit Care Med 2013;17:10-5.  Back to cited text no. 3
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Kocum A, Sener M, Calıskan E, Bozdogan N, Atalay H, Aribogan A, et al. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. J Cardiothorac Vasc Anesth 2011;25:1018-23.  Back to cited text no. 4
Thakur A, Kaur K, Lamba A, Taxak S, Dureja J, Singhal S, et al. Comparative evaluation of subclavian vein catheterisation using supraclavicular versus infraclavicular approach. Indian J Anaesth 2014;58:160-4.  Back to cited text no. 5
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Prasad PK, Sophia P, Lakshmi BS, Chandana K. Evaluation of the efficacy of supraclavicular approach for subclavian vein catheterization in Intensive Care Unit patients: A series of 50 cases. Int J Sci Study 2015;3:20-4.  Back to cited text no. 6
Aziz N, Khan A, Iqbal J. Subclavian vein catheterization: Supraclavicular versus infraclavicular approach. J Med Sci 2013;2:187-9.  Back to cited text no. 7
Cunningham SC, Gallmeier E. Supraclavicular approach for central venous catheterization: “Safer, simpler, speedier”. J Am Coll Surg 2007;205:514-6.  Back to cited text no. 8
Lu WH, Yao ML, Hsieh KS, Chiu PC, Chen YY, Lin CC, et al. Supraclavicular versus infraclavicular subclavian vein catheterization in infants. J Chin Med Assoc 2006;69:153-6.  Back to cited text no. 9
Ahn JH, Kim IS, Shin KM, Kang SS, Hong SJ, Park JH, et al. Influence of arm position on catheter placement during real-time ultrasound-guided right infraclavicular proximal axillary venous catheterization. Br J Anaesth 2016;116:363-9.  Back to cited text no. 10
Hiwarkar P, Sonkusare M, Deshpande R, Kasatwar A. Retrospective analysis of incidence of complications of central venous catheterization at an Intensive Care Unit. Int J Biomed Res 2015;6:279-84.  Back to cited text no. 11
Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: The forgotten central line. West J Emerg Med 2009;10:110-4.  Back to cited text no. 12
Hussain S, Khan RA, Iqbd M, Shafig M. A comparative study of supraclavicularversus infraclavicular approachfor central venous catheterization. Anesth Pain Intensive Care 2015;15:13-6.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]

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