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Ultrasound-Guided Cannulation of the Brachiocephalic Vein in Infants and Children is Useful and Stable/Bebeklerde ve Cocuklarda Ultrason Kilavuzlugunda Brakiyosefalik Ven Kanulasyonu.

Abstract / Oz

Objective: Ultrasound-guided (USG) cannulation of the brachiocephalic vein (BCV) has been shown to be technically easy. We hypothesised that adoption of USG in-plane cannulation of the BCV as the primary approach to central venous cannulation at our institution would lead to central venous cannulation for a greater variety of indications.

Methods: We performed retrospective, descriptive comparison of all central lines placed in patients aged < 16 years who underwent any surgical operation during calendar years 2012-2014 at a small, free-standing children's hospital. The use and management of a central line was reviewed until the patient was discharged from the hospital. Analysis of the data was performed using simple comparative statistical methods.

Results: Forty-nine patients were identified, 20 who weighed < 10 kg and 29 who weighed >10 kg. Cannulation was successful in all patients. No significant late complications occurred. Catheters were well tolerated post-operatively, with no accidental dislodgement and no removal because of discomfort. The average duration of insertion was 6.3 (3-20[+ or -]3.77) days. Nine catheters were placed for access during emergency surgery. 15 were placed in patients with difficult peripheral intravenous (PIV) access. The central lines remained in place until discharge in 79.6% of patients. In 40% of patients, the PIV catheter was removed, and the central line was retained because of preference. Total parenteral nutrition (TPN) was administered in 11 (22.4%) patients.

Conclusion: Cannulation of BCV was well tolerated by children, with an average insertion duration of 6.3 days, which often lasted beyond the removal/failure of the PIV cannula. Catheters were useful for primary venous access during hospitalisation and for short TPN courses.

Keywords: Brachiocephalic vein, central venous cannulation, paediatric, ultrasonography

Amac: Ultrason rehberliginde (USG) brakiyosefalik ven (BCV) kanulasyonunun teknik olarak zor olmadigi gosterilmistir. Uygulama kolayhgi ve hasta rahatindan dolayi, bizim kurumumuzda santral ven kanulasyonu icin ilk yaklasim olarak kabul edilmesinin, santral ven kanulasyonu endikasyonlarim genisletebilecegini varsaymaktayiz.

Yontemler: 2012-2014 yillari arasinda bagimsiz bir cocuk hastanesinde herhangi bir cerrahi operasyon geciren 16 yas altindaki hastalarin santral yollari retrospektif olarak incelendi. Hastaneden taburcu olana kadar yollarin kullammi ve yonetimi incelendi. Verilerin analizi karsilastirmali istatistik yontemleri ile yapildi.

Bulgular: Kirk dokuz olgu belirlendi. Bunlarm 20'sinin agirligi 10 kg'in altinda iken, 29'unun agirligi 10 kg'in uzerindeydi. Tum vakalarda kanulasyon basariliydi. Onemli gec komplikasyonlar gorulmedi. Kateterler kazayla yerlerinden cikmadan ve rahatsizlik nedeniyle cikarilmadan ameliyat sonrasinda iyi tolere edildiler. Kateterlerin ortalama kalis suresi 6,3 gun (3-20[+ or -]3,77) olarak bulundu. Dokuzunda acil cerrahide girisi saglamak icin yerlestirildi. On bes olguda bilinen veya karsilasilan zor periferik intravenoz (PIV) giris icin yerlestirildi. Olgulann %79,6'sinda kateterler, hasta eve taburcu olana kadar yerinde kaldi. Vakalann %40' inda PIV kateteri cikarildi ve santral tup tercihe bagli olarak birakildi. On bir hastada (%22,4) total parenteral nutrisyon (TPN) uygulandi.

Sonuc: BCV kanulasyon, genelde PIV kanulun cikarilmasi/basarisizliginin otesinde, ortalama 6,3 gunluk kalis suresiyle cocuklar tarafindan iyi tolere edildi. Kateterler hastane yatisi sirasinda primer venoz girisi olarak ve kisa sureli TPN yontemi acisindan faydali bulundu.

Anahtar Kelimeler: Brakiyosefalik ven, santral venoz kanulasyon, pediatrik, ultrasonografi


The brachiocephalic vein (BCV) occurs at the confluence of the internal jugular (IJ) and subclavian veins. The paired BCVs merge into the superior vena cava. The left BCV may rarely continue as a persistent left superior vena cava. BCV was previously known as the innominate vein or the Vein without a name'. On the right side, BCV t is sometimes referred to as the superior portion of the superior vena cava, whereas on the left side, it is sometimes referred to as the continuation of the subclavian vein.

Cannulation of BCV was initially described in 1965 by Yoffa (1) as a landmark-based approach in the supraclavicular fossa. Illustrations in that study clearly indicated that the needle was intended to enter what we now call BCV, although Yoffa used the older nomenclature of 'subclavian' and 'Pirogoff's confluence'. This approach may not have gained popularity because of early reports of pneumothorax in 1969 (2). Whether owing to concerns of causing pneumothorax, or confusion in the nomenclature, widespread adoption did not occur, leading to some authors to call the BCV approach 'the forgotten central line' (3, 4).

With the introduction of ultrasound into routine clinical practice, the brachiocephalic approach has regained interest because of the superficial location of BCV, and lack of bone overlying the vein, makes it possible to visualise the entire path of the needle during cannulation. In 2011, Breschan et al. (5) first described USG cannulation of BCV in children. They studied placement in children aged 26 months to 8 years. In the same year, Rhondali et al. (6) described placement in patients weighing <10 kg. Other studies have assessed placement in patients weighting <5 kg (7, 8). Three studies noted that USG BCV cannulation is technically easy in children in the paediatric intensive care unit and neonatal intensive care unit (8-10).


The internal review boards of Covenant Children's Hospital and Texas Tech University Health Sciences Center waived the requirement for informed consent for this retrospective, observational study. The study was conducted as per the protocol approved by both internal review boards.

A single anaesthesiologist began performing USG cannulation of BCV in January 2012 at our institution shortly after its initial description in the literature. Before that, central lines were infrequently placed; therefore, a case--control study was not possible given the lack of a historical control group. Patients in this study were consecutive cases of central venous cannulation by the author during calendar years 2012-2014. This study analyses the duration of insertion and characterisation of venous access at removal as primary outcome measures. Patients with central line placement were identified by billing records and case logs. Charts were reviewed via the electronic medical record for measurements of interest. Fifty-seven patients were identified. Six adults were excluded from this review, leaving 49 paediatric patients for review. Statistical analysis was performed with basic spreadsheet functions such as average, mean and standard deviation.

The SonoSite S-Series machine (Bothell, WA, USA) was used with a sterile sheath probe cover. For children weighing <10 kg, a narrow linear 13-6 MHz probe (LX25x, SonoSite) was used, and a 5-Fr 8-cm double-lumen catheter was chosen. For very small infants, a 5-cm double-lumen catheter was chosen, especially if cannulation of the right side was anticipated. For children weighing >10 kg, a linear 15-5 MHz probe (HFL50x, SonoSite) was used along with a 5-Fr 8- or 12-cm catheter. Portable radiograph confirmed placement before the child left the operating room.

The entry site of the catheter was covered with a Chlorhexidine gluconate impregnated patch (BIOPATCH[R] Ethicon, Somerville, NJ, USA) and secured with Mastisol[R] (Ferndale IP Inc., Ferndale, MI, USA) and Tega-derm[TM] (3M, St. Paul, MN, USA).

Coincident with our adoption of the USG BCV cannulation technique, our institution also implemented an algorithm intended to limit the number of attempts made to place a PIV cannula in children to prevent trauma and loss of useful veins. The "Difficult IntraVenous Algorithm" advised that after 5 attempts, or twenty minutes of attempts at placing a PIV, the involved team caring for the child was to pause and reflect on the value of continuing to search for a PIV, or consider another method of establishing venous access. In the operating room, the most common method chosen in this situation was USG BCV cannulation by anesthesiology.


Forty-nine patients were identified, 20 weighing <10 kg and 29 weighing >10 kg. Cannulation was successful in all patients. Patient weights ranged from 1.4 to 88 kg. Descriptive and calculated variables are presented in Table 1. All central lines were placed in the operating room during the induction of anaesthesia. Nine catheters were placed for resuscitation during emergency surgery, three of which were in infants weighing <10 kg. Fifteen catheters were placed for known or encountered difficult intravenous access or no intravenous access status. The rest of the catheters were placed for craniotomy, thoracic, major abdominal or major orthopaedic surgeries.

Central line cannulation of the BCV was successful in all patients. Difficulty was noted in three patients, one with arterial puncture, and two with difficulty threading the wire. All three were managed successfully by changing the approach to the contralateral side. Placement was on the left side in 31 (63.2%) patients.

The average insertion duration was 6.3[+ or -]3.77 (2-20) days. In patients weighing <10 kg, the average insertion duration was 7[+ or -]4.10 (3-20) days, which remained in place slightly longer than that in patients weighing >10 kg. There were no cases of thrombosis, infection, accidental removal or pneumothorax. Three patients who experienced fever postoperatively with temperature >38.1[degrees]C had their central lines removed per sepsis workup protocol. All three had sources of infection (surgical) far removed from site of cannulation. Short courses of total parenteral nutrition (TPN) were administered in 11 (22.4%) patients. PIV cannula was removed within an average of 3 days post-operatively as per the hospital protocol or failure of PIV, and the central lines were kept in place as the primary venous access in 40% of patients. The central lines were removed within 2 hours of the patients being discharged from the hospital 79.6% of the time. In patients weighing < 10 kg, the central lines were more likely to be retained until discharge with 95% (19/20) remaining until being discharged home.


The benefits of USG cannulation of BCV include visualisation of the needle along its entire path from the skin to the vein, patient comfort when the catheter is secured over the top of the shoulder and ease of maintaining dressings, which may reduce incidence of early removal for contamination concerns. Cannulation of IJ, which despite being a large vein that is easy to cannulate, is often very uncomfortable for patients. Neck movement often disrupts the integrity of the catheter dressing, rendering the insertion site vulnerable to contamination. Likewise, it is difficult to maintain barrier sterility with femoral central lines because of patient movement, and patients may remain immobile owing to discomfort with femoral lines. The supraclavicular approach to BCV is unique in that the catheter dressing usually tightly adheres and inconspicuously drapes over the shoulder in a manner that does not restrict arm or neck motion. It does not transverse the pectoralis muscle; therefore, it is less likely to limit upper extremity movement compared with the infraclavicular subclavian approach. Cannulation of the BCV has been promoted to have a lower potential for contamination compared to internal jugular, subclavian, or femoral central lines (11).

Despite variation in nomenclature, the important distinction from other central venous approaches is that the catheter lies predominately within BCV, even if it enters through the distal portion of the subclavian vein into Pirogoff's confluence. Figure 1 shows an artist's rendition of the arrangement of anatomy and the cannulation approach. Figures 2 and 3 demonstrate the USG approach with confirmation of catheter placement obtained with plain film x-ray. The catheter can be secured across the top of the shoulder, and in this position it is not uncomfortable with movement of the head or arm (Figure 4).

Descriptions of USG cannulation of BCV may be confused with USG infraclavicular and supraclavicular cannulation techniques of the subclavian vein around the mid-portion of the clavicle (12-15). A recent meta-analysis of 10 studies in adult patients noted that employing ultrasound guidance for subclavian cannulation significantly reduced adverse events (16). There are insufficient studies of cannulation of BCV in children to complete a similar meta-analysis. , It is reasonable to assume that a reduction in complications would also be found.

In these patients, placement in the left BCV was more common but both sides are reported as being used successfully (17, 18). It may be helpful to scan both supraclavicular fossapre-procedure to evaluate which side has the most complete visualisation of the arc of the subclavian/brachiocephalic confluence (7).

Although we did not experience any adverse outcomes, this study was not designed to examine safety compared to other methods.


This study presents descriptive evidence that central lines in BCV are well tolerated by children and are a useful option for intermediate-term venous access in patients undergoing complicated surgery or those with known or anticipated difficult PIV cannulation. This case series uniquely follows patients until discharge and assesses how the central lines were used and managed. These lines were retained post-operatively for an average of 7 days because they are well tolerated by children, easy to care for and useful for intravenous access. USG supraclavicular in-plane cannulation of BCV is both useful and durable.

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Covenant Children's Hospital and Texas Tech University Health Sciences Center.

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared by the author.

Financial Disclosure: The author declared that this study has received no financial support.

Etik Komite Onayi: Bu calisma icin etik komite onayi Cocuk Hastanesi ve Texas Tech Universitesi Saglik Bilimleri Merkezi'nden alinmistir.

Hakem Degerlendirmesi: Dis bagimsiz.

Cikar Catismasi: Yazar cikar catismasi bildirmemistir.

Finansal Destek: Yazar bu calisma icin finansal destek almadigini beyan etmistir.


(1.) Yoffa D. Supraclavicular subclavian venipuncture and catheterisation. Lancet 1965; 2: 614-7. [CrossRef]

(2.) Walker MM, Sanders RC Pneumothorax following supraclavicular subclavian venipuncture. Anaesth 1969; 24: 453-60. [CtossRef]

(3.) Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterisation: the forgotten central line. West J Emerg Med 2009; 10: 110-4.

(4.) Sener M. Supraclavicular subclavian vein catheterisation is still forgotten. Pedi Anesth 2014; 24: 339-57.

(5.) Breschan C, Platzer M, Jost R Stettner H, Beyer AS, Feigl G, et al. Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children. Br J Anaesth 2011; 106: 732-7. [CrossRef]

(6.) Rhondali O, Attof R, Combet S, Chassard D, Siqueira MQ. Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach. Pedi Anesth 2011; 21: 1136-41. [CrossRef]

(7.) Breschan C, Graf G, Jost R, Stettner H, Feigl G, Goessler A, et al. Ultrasound-guided supraclavicular cannulation of the right brachiocephalic vein in small infants: a consecutive, prospective case series. Pedi Anesth 2015; 25: 943-9. [CrossRef]

(8.) Oulego-Erroz I, Alonso-Quintela P, Dominguez P, Rodriguez-Bianco S, Muniz-Fontan M, Munoz-Lozon A, et al. Ultrasound-guided cannulation of the brachiocephalic vein in neonates and infants. An Pediatr (Barc) 2016; 846: 331-6. [CrossRef]

(9.) Guilbert AS, Xavier L, Ammouche C, Desprez P, Astruc D, Diemunsch P, et al. Supraclavicular ultrasound-guided catheterisation of the subvlacian vein in paediatric and neonatal ICUs: a feasibility study. Pedi Crit Care Med 2013; 14: 351-5. [CrossRef]

(10.) DiNardo M, Stoppa F, Marano M, Ricci Z, Barbieri MA, Cecchetti C. Ultrasound-guided left brachiocephalic vein cannulation in children with underlying bleeding disorders: a retrospective analysis. Pedi Crit Care Med 2014; 15: e44-8.

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(12.) Kocum A, Sener M, Caliskan E, Bozdogan N, Atalay H, Aribogan A. An alternative central venous route for cardiac surgery: supraclavicular subclavian vein catheterisation. J Cardio Vasc Anesth 2011; 25: 1018-23. [CrossRef]

(13.) Sterner S, Plummer DW, Clinton J, Ruiz E. A Comparison of the supraclavicular approach and the infraclavicular approach for subclavian vein catheterisation. Ann Emerg Med 1986; 15: 421-4. [CrossRef]

(14.) Thakur A, Kaur K, Lamba A, Taxak S, Dureja J, Singhal S, et al. Comparative evaluation of subclavian vein catheterisation using supraclavicular versus infraclavicular approach. Indian J Anaesth 2014; 58: 160-4. [CrossRef]

(15.) Byon HJ, Lee GW, Park YH, Kim HS, Kim CS, Kim JT. Comparison between ultrasound-guided supraclavicular and infraclavicular approaches for subclavian venous catheterisation in children--a randomized trial. Br J Anesth 2013; 111: 788-92. [CrossRef]

(16.) Lalu MM, Fayad A, Ahmed O, Bryson GL, Fergusson DA, Barron CC, et al. Ultrasound-guided subclavian catheterisation reduced the frequency of adverse events compared with the landmark technique. Crit Care Med 2015; 43: 1498-507. [CrossRef]

(17.) Kulkarni V, Mulavisala KP, Mudunuri RK, Byalal JR. Ultrasound-guided supraclavicular approach to the subclavian vein in infants and children. Br J Anaesth 2012; 1: 162. [CrossRef]

(18.) Breschan C, Platzer M, Jost R Stettner H, Feigl G, Likar R. Ultrasound-guided supraclavicular cannulation of the brachiocephalic vein in infants: a retrospective analysis of a case series. Pedi Anesth 2012; 22: 1062-7. [CrossRef]

Mark E. Thompson (1,2,3)

(1) Department of Anesthesiology State University of New York at Buffalo, Buffalo NY, USA

(2) Department of Anesthesiology Texas Tech University of Health Sciences, Lubbock TX, USA

(3) Department of Anesthesiology Covenant Children's Hospital, Lubbock TX, USA

Poster abstract presentation at Post- Graduate Assembly of the New York State Society of Anesthesiology, New York City New York USA, December 2015.

Bu arastirma, Aralik 2015 tarihinde New York Anesteziyoloji Dernegi Lisansustu Egitim Kurulu, ABD'de poster ozeti olarak sunulmustur.

Address for Correspondence/Yazisma Adresi: Mark E. Thompson E-mail:

[c] Copyright 2017 by Turkish Anaesthesiology and Intensive Care Society - Available online at

[c] Telif Hakki 2017 Turk Anesteziyoloji ve Reanimasyon Dernegi - Makale metnine web sayfasindan ulasilabilir.

Received / Gelis Tarihi : 05.01.2017

Accepted / Kabul Tarihi : 18.04.2017

An editorial comment on this article is available at page 127.
Table 1. Description of patients (n=49)

                            <10 kg (n=20)

Age (range)                  10.6 (1-30) mo ([dagger])
Weight in kg (0) (range)      7.46[+ or -]2.04 (1.4-9.8)
Duration in days (range)      7[+ or -]4.10 (3-20)
Removed at discharge         95% (19/20)
Used for TPN                  5
Emergency surgery             3
Difficult venous access      10
Left/Right sided             12/8

                            >10 kg (n=29)

Age (range)                   5.3 (1-16) yr ([double dagger])
Weight in kg (0) (range)     22.44[+ or -]17.54 (10.1-88)
Duration in days (range)      5.8[+ or -]3.51 (2-16)
Removed at discharge         68.9% (20/29)
Used for TPN                  6
Emergency surgery             6
Difficult venous access       5
Left/Right sided             19/10

                                Combined (n=49)

Age (range)                         3.8 yr (1 mo to 16 yr)
Weight in kg (0) (range)           16.33[+ or -] 15.38 (1.4-88)
Duration in days (range)            6.3[+ or -]3.77 (2-20)
Removed at discharge               79.6% (39/49)
Used for TPN                       11
Emergency surgery                   9
Difficult venous access            15
Left/Right sided                   32/19

TPN: total parenteral nutrition; ([dagger]) mo, months;
([double dagger]) yr, years; (0) kg, kilograms
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Title Annotation:Original Article / Ozgun Arastirma
Author:Thompson, Mark E.
Publication:Turkish Journal of Anaesthesiology and Reanimation
Article Type:Report
Date:Jun 1, 2017
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