An anatomic landmark to simplify subclavian vein cannulation: the "deltoid tuberosity".
The subclavian vein is frequently used to obtain central venous access. Several landmarks exist to determine the puncture site and angle, but they may require patient manipulation and anatomic measurements. We studied the feasibility of using the deltoid tuberosity, located on the lateral aspect of the clavicle, as an anatomic landmark. This would not necessitate these maneuvers and could therefore facilitate subclavian vein access. To systematically investigate this landmark, we conducted a study in four phases: 1) Two blindfolded examiners determined the distance between the tuberosity's medial border and the clavicle's lateral end in 100 dried clavicles and then 2) performed subclavian vein cannulation in 20 fresh human cadavers using the tuberosity and the suprasternal notch as landmarks. 3) Three-dimensional reconstructions of the subclavian artery and vein and surrounding structures were derived from computed tomography datasets of 10 patients. The length of the path of a virtual subclavian vein cannulation with the deltoid tuberosity landmark was measured bilaterally. 4) In a prospective, randomized trial, subclavian vein cannulation was performed in 60 patients with a standard approach or with the deltoid tuberosity as landmark. Interobserver difference between measurements in phase 1 was 3 +/- 1 mm (mean +/- sd); subclavian vein cannulation was achieved in 19 of 20 cases, whereas the subclavian artery was cannulated in one case (phase 2). In phase 3, there was no significant difference in skin-vein distance between the left (4.9 +/- 0.5 cm) and right (4.7 +/- 0.6 cm) sides. In phase 4, subclavian vein cannulation could be performed in all patients; moreover, subclavian vein cannulation was significantly (P < 0.01) faster in the deltoid tuberosity group versus the standard approach group (23 +/- 16 versus 34 +/- 14 s). We conclude that the clavicle's tuberosity may reflect an alternative anatomic landmark to simplify subclavian vein cannulation by minimizing patient manipulation and anatomic measurements.
von Goedecke
Achim
A
*Department of Anesthesiology and Critical Care Medicine; †Institute of Anatomy, Histology, and Embryology; ‡Department of Biostatistics and Documentation; §Department of Pathology; ∥Department of Radiology I (Interdisciplinary Stereotactic Intervention and Planning Laboratory), Medical University of Innsbruck, Innsbruck, Austria.
Keller
Christian
C
Moriggl
Bernhard
B
Wenzel
Volker
V
Bale
Reto
R
Deibl
Martina
M
Moser
Patrizia
P
Lirk
Philipp
P
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002405:Catheterization, Central Venous / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013350:Subclavian Vein / Q000033:anatomy & histology*
Eerola R, Kaukinen L, Kaukinen S. Analysis of 13,800 subclavian vein catheterizations. Acta Anaesthesiol Scand 1985;29:193–7.
Mansfield PF, Hohn DC, Fornage BD, et al. Complications and failures of subclavian-vein catheterizations. N Engl J Med 1994;331:1735–8.
Simpson ET, Aitchinson JM. Percutaneous infraclavicular subclavian vein catheterization in shocked patients: a prospective study in 172 patients. J Trauma 1982;22:781–4.
Sznajder JI, Zveibil FR, Bitterman H, et al. Central vein catheterization: failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259–61.
Seneff MG. Central venous catheters. In: Irwin RS, Rippe JM, Curley FJ, Heard SO, eds. Intensive care medicine, 3rd ed. Philadelphia: Lippincott, Williams and Wilkins 2003:17–35.
Lechner P, Anderhuber F, Tesch NP. Anatomical bases for a safe method of subclavian venipuncture: clinical experience in 350 cases. Surg Radiol Anat 1989;11:91–5.
Simon RR. A new technique for subclavian puncture. JACEP 1987;7:409–11.
Tripathi M, Tripathi M. Subclavian vein cannulation: an approach with definite landmarks. Ann Thorac Surg 1996;61:238–40.
Taylor BL, Yellowlees I. Central venous cannulation using the infraclavicular axillary vein. Anesthesiology 1990;72:55–8.
Moran SG, Peoples JB. The deltopectoral triangle as a landmark for percutaneous infraclavicular cannulation of the subclavian vein. Angiology 1993;44:683–6.
Federative Committee on Anatomical Terminology. Terminologia anatomica. Stuttgart: Thieme, 1998:19.
Gruber W. Ueber das Tuberculum deltoideum und den Processus deltoideus des Schluesselbeines. Archiv für Anatomie, Physiologie und wissenschaftliche Medicin 1871;3:297–9.
Fleiss J. Reliability of measurement, the design and analysis of clinical experiments. New York: John Wiley &Sons, 1986:2–32.
McGee DC, Gould MK. Preventing complications of central venous catheterizations. N Engl J Med 2003;348:1123–33.
Christensen KH, Nerstrom B, Baden H. Complications of percutaneous catheterization of the subclavian vein in 129 cases. Acta Chir Scand 1967;133:615–20.
Davidson JT, Ben-Hur N, Nathen H. Subclavian venipuncture. Lancet 1963;2:1139–40.
Jesseph JM, Conces DJ Jr., Augustyn GT. Patient positioning for subclavian vein catheterization. Arch Surg 1987;122:1207–9.
Tan B-K, Hong S-W, Huang MHS, Lee S-T. Anatomic basis of safe percutaneous subclavian venous catheterization. J Trauma 2000;48:82–6.
Lefrant JY, Cuvillon P, Benezet JF, et al. Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study. Anesthesiology 1998;88:1195–201.
Bold RJ, Winchester DJ, Madary AR, et al. Prospective, randomized trial of Doppler-assisted subclavian vein catheterization. Arch Surg 1998;133:1089–93.