Letter to the Editor in Reference to: Ultrasound-Guided Vascular Access Routes: An Overview

In Reference to:

Ultrasound-Guided Vascular Access Routes: An Overview

From Cath Lab Digest, Vol. 26, Issue 10, October 2018

Dear Editor,

We read with great interest the article by Abu Aquil and Merschen regarding ultrasound-guided vascular access.¹ We agree with the authors that ultrasound is a valuable tool that, if appropriately used, can reduce vascular access complications. In addition to the vascular access sites described in the article¹, we feel that it is important to also mention the subclavian vein. The subclavian vein, compared to other central vascular access sites (e.g., internal jugular and femoral veins), offers the potential of lower infectious and thrombotic events^2,3, in addition to greater patient comfort during long-term use. Historically, it has been the practice to access the subclavian vein using anatomic landmarks; however, this carries a risk of pneumothorax and inadvertent arterial puncture. Ultrasound guidance can increase the safety of this procedure, and the technique has been well described.² Once the vein and artery are identified by 2D imaging (Figure A), adjunct methods such as pulse-wave Doppler (Figure B) and color Doppler (Figure C) can be further used to differentiate the vein from artery. To further increase operator confidence (if the Doppler signals are of poor quality), the authors believe that injection of agitated saline into the ipsilateral upper extremity is also of benefit to identify the subclavian vein (Figure D). At centers that perform heart transplantation, the presence of invasive hemodynamic monitoring is one of the criteria for certain waitlist urgency statuses.⁴ Since patients often require long-term use of pulmonary artery catheters, familiarity with ultrasound-guided subclavian vein placement would be beneficial, mainly to reduce infection rates, and for patient comfort.

The authors can be contacted via Faris G. Araj, MD, at Faris.Araj@UTSouthwestern.edu.

Disclosures: Dr. Araj and Ms. Cox report no conflicts of interest regarding the content herein.

1. Abu Aquil A, Merschen RJ. Ultrasound-guided vascular access routes: an overview. Cath Lab Digest. 2018 Oct; 26(10). Available online at https://www.cathlabdigest.com/article/Ultrasound-Guided-Vascular-Access-Routes-Overview. Accessed February 11, 2019.
2. Schulman PM, Gerstein, NS, Merkel MJ, et al. Ultrasound-guided cannulation of the subclavian vein. N Engl J Med. 2018 Jul 5; 379(1): e1.
3. McGee DC, Gould, MK. Preventing complications of central venous catheterization. N Engl J Med. 2003 Mar 20; 348(12): 1123-1133.
4. Adult heart allocation. Organ Procurement and Transplantation Network. U.S. Department of Health & Human Services. Available online at https://optn.transplant.hrsa.gov/learn/professional-education/adult-heart-allocation. Accessed February 11, 2019.