Where antecubital catheters go: a study under fluoroscopic control

Fifty attempted central venous cannulations via the antecubital route were studied with fluoroscopy to determine catheter tip location. Only "catheter through needle" devices were employed. Successful central placement occurred on the first attempt in 27 cases. The major impediment to central location of the catheter tip (ten cases) was the tendency of the catheter tip to lodge at the subclavian-internal jugular vein junction. The second most common cause of noncentral location was migration of the catheter tip into the internal jugular vein (nine cases). One catheter tip was located in the contralateral subclavian vein and one ended in the external jugular vein. All of these problems were avoided by two maneuvers: 1) turning the patient's head toward the side of cannulation and applying digital pressure to the ipsilateral supraclavicular fossa, and 2) withdrawing the catheter stylet and injecting 5-10 ml of physiologic saline solution while the catheter was advanced. The only cause of unsuccessful central placement in this study was inability to pass the catheter tip past the axillary venous plexus (two patients). It is concluded that the head-turn-supraclavicular fossa pressure maneuver in combination with the stylet withdrawal-saline injection maneuver can result in greater than a 90% rate of successful central venous catheter placement.