Subclavian Cannulation. Supraclavicular Approach.
The subclavian vein can also be cannulated using a supraclavicular approach.This route is preferred by some authors.The essential landmark for the supraclavicular approach is the junction of the lateral border of the clavicular head of the sternocleidomastoid with the clavicle. The point of cutaneous puncture lies 1 cm superior and 1 cm lateral to this junction. The junction of the sternocleidomastoid with the clavicle defines the claviculosternomastoid angle.
The cannulating needle tip is angled posteriorly 5°–15° off a coronal plane and advanced along a line that bisects the claviculosternomastoid angle. This will lead to subclavian venipuncture between the clavicle and the anterior scalene muscle.Others suggest cutaneous puncture directly at the claviculosternomastoid angle and advancing the needle along the claviculosternomastoid angle bisector parallel and inferior to the clavicle to enter the vein at an insertion depth of 1–2 cm.
Anatomic data from three-dimensional computed tomography reconstructions suggest that, with the sternocleidomastoid-clavicular junction as a cutaneous puncture point, the needle should be oriented approximately 11° medially and 35° posteriorly as it is advanced approximately 1.4 cm to enter the vein; unfortunately relatively large standard deviations for these mean values limit their clinical utility. Supraclavicular subclavian cannulation can be facilitated by ultrasound guidance.
