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Indications / Contraindications
Indications
- Inability to achieve adequate peripheral venous access
- Medications unsafe via peripheral IV: TPN, vasopressors, chemotherapy, hypertonic solutions
- Frequent blood draws; central venous pressure monitoring
- Hemodialysis (acute); plasmapheresis
- Rapid volume resuscitation (large-bore access)
Contraindications
- Absolute: Combative/uncooperative patient; no safe access site
- Relative: Coagulopathy (SIR: INR ≤2.0, platelets ≥50K); active sepsis at proposed access site; prior radiation therapy traversing access site; suspected vein occlusion (confirm patency with US pre-procedure)
- Anticoagulation: Aspirin and Plavix do NOT need to be held. LMWH: hold 1 dose if feasible.
- Note: Clinical urgency frequently overrides ability to correct coagulopathy.
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Pre-Procedure Checklist
Review imaging. Review available imaging at proposed access site; avoid sites within prior radiation fields.
Pre-procedure US survey. Confirm target vein patency; identify variant anatomy; assess for existing thrombus; measure vein caliber.
Labs. INR ≤2.0 preferred (not strict); platelets ≥50K; clinical judgment prevails for urgent cases. All central venous access is low bleeding risk per SIR guidelines.
Anticoagulation. Aspirin/Plavix — no hold required; LMWH — hold 1 dose if feasible; urgent clinical situations override.
Preview with 25g needle. Consider pre-procedure 25g local needle under US to preview angles and depths before committing to larger access needle.
Sterile preparation. Full surgical scrub; sterile gown, gloves, cap, mask; 20×20 cm sterile prep and drape.
Consent. Arterial puncture, pneumothorax, hematoma, infection, air embolism, thrombosis, catheter malposition.
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Relevant Anatomy
Site-Specific Anatomy
- See Section 9 (Site Selection) for detailed site-by-site guide.
- IJ vein: Anterior-lateral to carotid artery; compressible on US; distends with Valsalva; right IJ provides direct path to SVC and right atrium
- Subclavian vein: Superficial to subclavian artery; distends with Valsalva; compressed under clavicle medially
- Femoral vein: Medial to femoral artery in femoral triangle; compressible; thrombosis risk ~20%
Target Tip Position
- IJ / Subclavian catheters: SVC–right atrial junction or upper right atrium (confirmed fluoroscopically)
- Femoral catheters: Tip at IVC–right atrial border
- Tip position must be confirmed fluoroscopically before line use
- Malposition into ipsilateral IJ, azygos vein, or contralateral brachiocephalic should prompt repositioning over wire
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Technique
Default RadCall approach · share your own below
Supplies
Sterile US probe cover
21g micropuncture kit (needle + 0.018" wire + coaxial sheath)
0.035" J-wire
Dilator
Triple-lumen 7Fr catheter
10 mL slip-tip syringe
1% lidocaine
25g + 21g needles (local anesthesia)
Sterile drape + ChloraPrep
#11 scalpel
Mosquito hemostat
2-0 nonabsorbable suture
Biopatch
Heparinized saline flush
Steps
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US survey
Confirm IJ patency. Sweep from IJ to brachiocephalic to rule out central stenosis or occlusion (attenuated IJ with collaterals suggests central occlusion). Identify carotid artery.
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Positioning
Supine, head turned away from access side. Trendelenburg to dilate IJ. Right IJ preferred.
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Sterile prep + local anesthesia
Full sterile prep and drape. Use 25g needle first under real-time US — preview angles and depths before committing to the 21g micropuncture needle. This 25g pass simultaneously provides local anesthesia to the tract.
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Single-wall venipuncture
Advance 21g micropuncture needle under REAL-TIME US. Orient probe parallel/cephalad to clavicle; aim for lateral wall of IJ. Proximal vein wall "tents" as needle approaches; apply minimal impulse to "pop" through. Needle tip should be echogenic within lumen.
▶ View IJ US access
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Microwire placement
Advance 0.018" microwire under fluoroscopy — direct tip caudally toward SVC. If resistance: check fluoro (wire deflecting superiorly = likely extravascular). Do NOT pull wire back through needle (shearing risk) — withdraw needle and wire as a UNIT if problem.
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Skin incision + blunt dissection
Skin incision along needle (blade directed away from carotid). Blunt dissection with mosquito hemostat — too small = resistance and kinking.
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Exchange to 0.035" system
Remove micropuncture needle; advance coaxial sheath; withdraw inner sheath and microwire. Keep finger over hub to minimize bleeding and air embolus.
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Catheter placement
Advance 0.035" J-wire to IVC under fluoroscopy to confirm venous position. Advance catheter over wire to target position (SVC-RA junction).
▶ View wire to IVC
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Confirm + secure
Confirm tip position fluoroscopically. Aspirate all lumens; flush with heparinized saline. Suture with 2-0 nonabsorbable (×2 sites). Biopatch at skin entry.
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Troubleshooting
Problem
Wire deflects superiorly (into IJ / not heading to SVC)
Likely cause: Needle tip not in SVC; wire following extravascular or wrong track; needle angled too superiorly.
Next step: Withdraw needle and wire as a unit. Reattempt with needle directed more caudally. Advance wire under fluoroscopy to confirm trajectory toward SVC before exchanging sheath.
Problem
Wire kinks on exit through skin
Likely cause: Skin incision too small; subcutaneous tract not adequately blunt dissected.
Next step: Replace with new wire. Ensure skin incision is adequate and bluntly dissect the tract with mosquito hemostat before re-exchanging.
Problem
Cannot compress vein / suspected thrombosis
Likely cause: Acute or chronic DVT at target site.
Next step: Perform full US survey; confirm with power Doppler. Do NOT puncture thrombosed vein. Switch to alternative site.
Problem
Inadvertent carotid / arterial puncture
Likely cause: Medial needle trajectory; excessive pulsatile flow on aspiration; bright red blood.
Next step: Remove needle; apply gentle pressure × 5–10 min. Abandon this access level; reassess and attempt IJ at different level or opposite side. If large sheath already placed in carotid — do NOT remove at bedside (risk of massive hematoma) — vascular surgery emergency.
Problem
No blood return
Likely cause: Needle not deep enough; posterior wall puncture; needle outside lumen.
Next step: Advance needle slightly under US; rotate bevel; try repuncture. Needle may have passed through posterior wall — withdraw slowly under US while aspirating.
Problem
Catheter kinking at skin
Likely cause: Skin incision too small; subcutaneous tract underdissected.
Next step: Pull back catheter; enlarge incision with hemostat; re-advance catheter.
Problem
Air embolism (sudden hemodynamic collapse, "mill-wheel" murmur)
Likely cause: Air entrainment during sheath exchange or catheter placement; hub left open.
Next step: Immediately left lateral decubitus + Trendelenburg; 100% O2; aspirate through catheter; hyperbaric O2 if available.
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Complications
Procedural
- Arterial puncture (1–3%): Remove needle, firm pressure ×10 min. Do not dilate or place catheter in artery. If large sheath placed in carotid — do NOT remove at bedside — vascular surgery emergency.
- Pneumothorax (1–3%, IJ/subclavian): Uncommon with US guidance. Small/stable → supplemental O2 ± serial CXR. Large/symptomatic → small-bore chest tube.
- Hematoma (1–3%): Compression; usually self-limited.
- Air embolism (<1%): See troubleshooting above.
Delayed
- CLABSI (1–3%): Remove non-tunneled line; blood cultures; IV antibiotics; place new line if still needed.
- Venous thrombosis: IJ/subclavian ~4%; femoral ~20%. Anticoagulation; remove catheter when no longer needed.
- Catheter malposition: Detected on CXR; requires repositioning over wire under fluoroscopy.
- Overall major complication rate with image guidance: ~3%; technical success >99% with US guidance.
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Post-Procedure Care
Confirmation + Securing
- Fluoroscopic confirmation of tip at SVC-RA junction required before use
- Line secured with 2-0 nonabsorbable suture ×2 sites; Biopatch at skin entry
- All lumens flushed with heparinized saline; volume per lumen marked on catheter
Ongoing Line Care
- Daily assessment of line necessity — remove as soon as no longer needed (reduces CLABSI risk)
- Dressing change per institutional protocol (usually q7d with chlorhexidine-impregnated dressing)
- Suspected CLABSI: Draw blood cultures from line AND peripheral; consider catheter removal
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Critical Pearls
✦
Always confirm venous access with US and fluoroscopy before dilation: Arterial dilation is a serious, potentially catastrophic complication. Confirm wire courses toward the SVC under fluoroscopy — not toward the aorta — before exchanging to 0.035" system and dilating.
✦
Right IJ is preferred first access: Largest caliber, most direct path to SVC, fewest turns. Puncture low in the neck (near clavicle): more comfortable, less catheter protrudes, and facilitates future tunneling for dialysis conversion if needed.
✦
NEVER pull the guidewire back through the needle: Shearing risk. Always withdraw needle and wire as a unit if repositioning is needed.
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Adequate skin incision and blunt dissection: A too-small skin incision causes wire kinking and loss of tactile feedback. Bluntly dissect with mosquito hemostat until resistance is gone before advancing catheter.
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Preserve subclavian veins: In any patient who may ever need hemodialysis (AV fistula/graft outflow), avoid subclavian access — subclavian stenosis can permanently compromise upper extremity AV access.
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Femoral access is last resort: ~20% thrombosis rate, highest infection risk. Reserve for emergencies or when upper body access is exhausted.
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25g needle preview: The 25g local anesthetic needle under US previews angles and depths before you commit to the micropuncture needle — use this every time.
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Watch for wire balling or looping under fluoroscopy: This suggests extravascular position. Do not dilate. Withdraw wire and needle as a unit and reattempt.
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IVC filter caution: If wire loops into IVC filter — do not advance wire through filter; redirect under fluoroscopy.
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Left subclavian preferred over right: Less acute brachiocephalic-SVC angle makes wire/catheter navigation easier from the left subclavian approach.
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Site Selection
Site-by-site anatomy, technique, and tradeoffs
| Site | Status | Anatomy & Technique | Advantages | Avoid When |
|---|---|---|---|---|
| Right IJ | Preferred | Anterior-lateral to carotid; larger caliber than left IJ; direct straight path to SVC and RA. US probe parallel/cephalad to clavicle; target lateral wall of IJ; puncture low (near clavicle); keep carotid visible on US at all times. | Least complication risk; easiest tunneling if conversion to tunneled dialysis catheter needed. | Right neck lymphadenopathy, prior radiation, or ipsilateral AV fistula planned. |
| Left IJ | Acceptable | Two ~90° turns at IJ-brachiocephalic junction and brachiocephalic-SVC junction. Use stiff hydrophilic wire to navigate turns; advance wire under fluoroscopy. | Acceptable alternative when right IJ unavailable. | Slightly higher catheter kink and malposition rate vs. right IJ. Avoid if right IJ is accessible. |
| External Jugular (EJ) | Acceptable | Visible and palpable lateral neck; US identifies it superficial to the SCM. Advance wire carefully — acute angle at EJ–subclavian junction; hydrophilic wire or stiff wire may be needed. Direct visualization often possible without US. | No arterial puncture risk. Viable when both IJ sites are occluded or unavailable. | Tortuous anatomy common; higher malposition rate. Reserve for cases where IJ is inaccessible. |
| Subclavian | Caution | Access via lateral half of clavicle (avoids "pinch-off" at medial clavicle-rib compression). Transducer perpendicular to clavicle — simultaneously visualize subclavian vein, artery, and pleura. Left subclavian preferred over right (less acute angle into SVC). | Acceptable when IJ sites unavailable. Lower infection rate than femoral. | Any patient who may ever need hemodialysis (AV fistula/graft outflow). Associated with higher rates of subclavian stenosis, thrombosis, and irreversible compromise of upper extremity AV access. Pneumothorax risk 1–3%. |
| Femoral | Last Resort | Femoral vein is medial to femoral artery; access ideally over femoral head. Needle at 45° aiming cephalad; advance 5 mm medial to femoral arterial pulse. Tip position: IVC–right atrial border (not SVC-RA junction). | No pneumothorax risk; useful in coagulopathic patients where compression is feasible; accessible during CPR. | Ambulatory patients; immunocompromised; patients who will be mobilized. Thrombosis rate ~20%; highest infection risk of all sites. |
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- SIR Standards of Practice for Venous Access
- ACR-SIR-SPR Practice Parameter for Central Venous Access
- SCCM/IDSA CLABSI Prevention 2022
Primary References
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123-1133.
- Sznajder JI et al. Central vein catheterization: failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986;146(2):259-261.
- Troianos CA et al. Guidelines for performing ultrasound guided vascular cannulation. J Am Soc Echocardiogr. 2011;24(12):1291-1318.
- Brass P et al. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev. 2015;(1):CD011447.