Brachiocephalic Vein
Technique: Shoulder roll, head rotated roughly 45° to the contralateral side. First, identify the ipsilateral Internal Jugular (IJ) vein. After the IJ is identified, slide the probe caudad toward the clavicle until the IJ-Subclavian junction is identified. Now, tracing the subclavian medially, the probe is angled slightly into the thorax, and rotated clockwise (if accessing on the right) or counter-clockwise (if accessing on the left). The goal is to trace the subclavian until it can be seen diving inferomedially as the brachiocephalic vein. The pleura serves as a lateral boundary. Once the brachiocephalic vein is identified, the needle is advanced in-plane under direct ultrasound guidance. If the angle of approach or the visual target preclude an in-plane approach, an out-of plane technique can be performed in a similar fashion many would do an IJ central line. With the pleural potentially millimeters away, care should be exercised as one advances the needle with a careful eye on local tissue distortion to guide your pathway. If performing this technique on the left, right-handed practitioners may choose to stand in the patient’s left axilla to better approximate the path of brachiocephalic vein and desired angle of approach; vice-versa for left-handed practitioners and right-sided brachiocephalic lines.
Risks:
General risks: bleeding, infection, possibly arterial injury
Pneumothorax; Non-compressible bleeding; Hemothorax
Sonoanatomy
After the Pirotte & Veyckemans paper describing the infraclavicular approach to the subclavian vein was published, Breshen et al realized that they were able to get an excellent view of the brachiocephalic vein (BCV) when scanning in the supravicular region. In their prospective case series of ultrasound-guided BCV cannulations in 35 consecutive patients, they had a 100% success rate, though 11.9% required a third attempt. Low weight and younger age were associated with a statistically significant difference in puncture attempts.
In 2012, Breschan et al looked to see if cannulating left vs right had an impact on success. In this retrospective study, while they found that there was an overall success rate of 98.9%, first pass success for the left was more than double that of the right (82.9% vs 38.4%). Overall, they also found significantly more puncture sites on the right. It was hypothesized this was due to anatomical differences in the trajectory of the BCV. With this in mind, once again, Breshan et al evaluated whether there was an association between preprocedural ultrasonography of the right BCV and cannulation attempts. They classified their imaging of the BCV as either class I (full longitudinal view of the BCV) or class II (partial, circular view of the BCV). They found that 90% of class I right BCV’s were successfully cannulated on the 1st attempt compared to only 41.4% of class II views. In fact, 24% required at least 3 attempts, and of those requiring at least 3 attempts, almost 30% were unable to be cannulated at all.
Breschan et al recently published a retrospective article describing their experience performing supraclavicular, ultrasound-guided (BCV) cannulations in preterm infants. During a 7-yr period, 142 BCVs were cannulated in babies weighing a median of 2.1kg, though ranged from 0.59- 2.5kg. They found an ultimate success rate in the primary target vein of 94%, though some patients did require second or even third attempts. The right BCV was technically more challenging, and multiple attempts was associated with a circular sonographic appearance of the BCV, rather than a longitudinal long-axis view. The number of attempts was also inversely correlated to patient weight: the smaller the infant, the more attempts.
This approach, much like the subclavian vein, has the advantage of vessel non-compressibility, which may be an aid during cannulation. The left BCV may be technically easier, as it has a more horizontal course compared to the more vertical right BCV. Difficulty obtaining a longitudinal view of the right BCV (may sometimes appear as if in cross section and only visualized as a circular object) can alert practitioners that perhaps an alternate cannulation site should be considered.
Pirotte, T. and Veyckemans, F., 2007. Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach. British Journal of Anaesthesia, 98(4), pp.509-514.
Breschan, C., Platzer, M., Jost, R., Stettner, H., Beyer, A.S., Feigl, G. and Likar, R., 2011. Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children. British journal of anaesthesia, 106(5), pp.732-737.
Breschan, C., Platzer, M., Jost, R., Stettner, H., Feigl, G. and Likar, R., 2012. Ultrasound-guided supraclavicular cannulation of the brachiocephalic vein in infants: a retrospective analysis of a case series. Pediatric Anesthesia, 22(11), pp.1062-1067.
Breschan, C., Graf, G., Jost, R., Stettner, H., Feigl, G., Goessler, A., Neuwersch, S., Koestenberger, M. and Likar, R., 2015. Ultrasound-guided supraclavicular cannulation of the right brachiocephalic vein in small infants: a consecutive, prospective case series. Pediatric Anesthesia, 25(9), pp.943-949.
Breschan, C., Graf, G., Jost, R., Stettner, H., Feigl, G., Neuwersch, S., Stadik, C., Koestenberger, M. and Likar, R., 2018. A retrospective analysis of the clinical effectiveness of supraclavicular, ultrasound-guided brachiocephalic vein cannulations in preterm infants. Anesthesiology: The Journal of the American Society of Anesthesiologists, 128(1), pp.38-43.