Procedural, Sound Rounds

Sound Rounds: US-Guided Subclavian Cannulation

Welcome to another edition of Sound Rounds (finally)! This morning (well, Tuesday morning, when I started writing this post…), we had the pleasure of Dr. Kevin Gurysh (our current EUS fellow) teach us a new technique of placing a subclavian central venous catheter under ultrasound guidance. The lesson was inspired by (stolen from?) this episode of the Ultrasound Podcast, which was an interview with Mourad H. Senussi, the lead author of this article published in the Journal of Intensive Care Medicine.

The idea is fairly simple – use an existing impenetrable structure as a “backstop” to prevent yourself from even being able to puncture the deeper structures, thereby making it effectively impossible to cause that ever-dreaded complication of subclavian lines: the pneumothorax. And thusly was born the PART method – Pleural Avoidance with Rib Trajectory.

MVIMG_20180410_112022.jpg
Dr. P and Dr. Gurysh identifying the anatomy involved in the PART technique

Feel free to read the article and watch the podcast, but the very basic idea is to identify the subclavian/axillary vein lateral to where it dives under the clavicle and then perform an in-plane cannulation of the vessel aiming your introducer needle at the second rib so that if you do end up going through the back wall of the vessel, the rib will naturally serve as a backstop to prevent your needle from continuing on its merry way into the lung.

Short Axis Veins
Orientation of the probe to identify the relevant anatomy in short axis. Probe footprint is in the top left of the screen. Red box is the footprint of the linear probe, with the indicator shown in green.
Short Axis-01
Short axis anatomy lateral to the sternum (this is the right side of the body). C = clavicle; M = muscle; V = vein; A = artery; L = lung.

The first step is to use the probe to identify the subclavian/axillary vein in short axis as shown in the diagram above. Once you have something that looks like that, rotate into long axis on the vein (as always, a very simple maneuver, but not easy) and obtain the view shown below.

Long Axis Veins
Orientation of the probe in long axis to the vein.
Long Axis
Long axis anatomy. R = 2nd rib. Attempting to cannulate the vein while aiming for the rib prevents accidental pneumothorax.

Once you find this view, all that remains is to cannulate the vein using an in-plane technique while aiming for the rib so that if you accidentally pass through the back wall, you won’t also accidentally pass into the lung.

And that’s it! Super easy, right? Hit us up below and let us know if you’ve ever used this technique or if you plan to use it in the future. As always…happy scanning!

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