Written By Chris Thom
Spoon Feed
In this randomized control trial of left versus right ultrasound-guided infraclavicular subclavian central venous access, the left-sided approach was associated with a lower catheter malposition rate.
Let’s avoid that turn cephalad into the IJ
This was an RCT of left versus right ultrasound-guided infraclavicular central access among patients undergoing general anesthesia for elective procedures. Five right-handed anesthesiologists participated in the study, with 225 patients allocated to the left SVC (subclavian vein catheterization) cohort and 225 to the right SVC cohort. The overall rate of catheter malposition following insertion was 13.8% in the right-side and 4.5% in the left side, p=0.001. This was associated with an odds ratio of 0.29 (95% CI 0.14-0.61) favoring the left-sided approach. The majority of malpositions were into the ipsilateral internal jugular vein (33), with 8 being in the contralateral brachiocephalic vein. First-pass success was higher in the left sided approach, with 39.3% in the left group as compared to 28.9% in the right group, p=0.020. Overall success rate for catheter placement was similar between cohorts.
How will this change my practice?
In this well-executed RCT, the left infraclavicular SVC location led to improved outcomes compared to the right. Previous research has led many doing landmark SVCs to favor the right side, as the left subclavian vein may be smaller, and there is a risk of thoracic duct injury. However, the angle between the left subclavian vein and the IJ may be more favorable to avoiding an ipsilateral IJ malposition. Given that ultrasound guidance allows us to more safely avoid unintended structures and to gain access to smaller target vessels, the scale has likely tipped towards favoring the left SVC for the infraclavicular approach. However, the authors did not assess guidewire position with ultrasound prior to dilation and catheter placement. It is relatively easy to bring the probe back onto the field after wire placement to ensure that the wire is in the appropriate vessel at the entry point, but also to survey the ipsilateral IJ to ensure no presence of wire. This practice would have avoided the majority of the malpositions in this study and should also be further investigated.
Source
Comparison of Catheter Malposition Between Left and Right Ultrasound-Guided Infraclavicular Subclavian Venous Catheterizations: A Randomized Controlled Trial. Crit Care Med. 2024 Oct 1;52(10):1557-1566. doi: 10.1097/CCM.0000000000006368. Epub 2024 Jun 24. PMID: 38912886
Editorial: Nunnally ME. Subclavian Catheter: When Ultrasound Tells Us Left Is “Right”. Crit Care Med. 2024;52(10):1653-1655
