The complications of subclavian venepuncture include:

Inadvertent subclavian arterial puncture.
Inadvertent subclavian arterial puncture is a relatively common complication of subclavian venepuncture. The overall reported incidence is in the range of 1 - 13% with 2 - 5% being typical. This incidence increases to about 40% if multiple attempts are made ¹. The consequences of subclavian arterial puncture are not as potentially serious as the consequences of inadvertent internal carotid puncture during attempted internal jugular venepuncture as the risk of a cerebral thromboembolic event or airway compromise is practically nil. However, bleeding from the subclavian artery is much more difficult to control by pressure alone and if bleeding occurs, it may be more easily missed because the blood may track into the pleural cavity. It is for this reason that the subclavian route is generally thought to be the least suitable approach to the central circulation in the anticoagulated patient.

Subclavian arteriovenous fistula ² and aneurysm ³ formation following inadvertent subclavian arterial puncture have both been described.

Inadvertent internal mammary arterial puncture.
The internal mammary artery (IMA) arises from the first part of the subclavian artery, close to the medial margin of scalenus anterior. Thus, it can be argued that an ipsilateral subclavian approach to the central circulation is contraindicated in patients undergoing internal mammary artery grafting in case the origin of the IMA is damaged. In practice, this does not appear to be the case and there are few reports of IMA damage complicating subclavian venepuncture ^{4, 5}. One of the authors (DAP), has successfully used the left subclavian approach on more than 5000 occasions in patients undergoing internal mammary artery grafting.

Pneumothorax.
Pneumothorax is one of the most common major complications of the technique. The overall incidence is typically quoted at between 1% and 2% ^{6, 7}, but this increases to about 10% if multiple attempts at venepuncture are made ¹. It occurs more commonly in thin patients and in those with hyperexpanded chests. It is also more likely if a lateral or supraclavicular approach to the subclavian vein is used, or if the Seldinger needle is allowed to stray posteriorly during venepuncture (Figure 1). Depending on the size of the pneumothorax, treatment may range from the administration of oxygen (to enhance resolution) through to formal chest drainage. There are frequent reports of delays in the appearance of a pneumothorax for up to 96 hours after venepuncture ^{8, 9, 10}. For this reason the place of early (within 1-2 hours) chest radiography in the diagnosis of this complication is questionable.

A meta-analysis by Plewa et al ¹¹ suggested that delayed pneumothorax complicated approximately 0.4% of all central venous access attempts, was much more common after subclavian than internal jugular approaches, was asymptomatic in about 22% of cases and resulted in a tension pneumothorax in a similar proportion.

Venous Air Embolism.
This complication is addressed in the section devoted to the complications of internal jugular venepuncture. It has been reported as a lethal complication of subclavian venepuncture ¹².

Thoracic duct injury.
If a left-sided subclavian approach is used, thoracic duct injury can occur ¹³. The complication is rare and has also been reported with left internal jugular catheterisation ¹⁴. The point of damage to the thoracic duct is usually at its site of insertion at the confluence of the internal jugular and subclavian veins (Figure 2). Chylothorax then results. The condition is notoriously difficult to treat and is the major reason for selecting the right-sided approach to the subclavian vein in preference to the left. Chylous fistula has never been reported as a complication of subclavian cannulation.

Subclavian vein thrombosis.
Subclavian vein thrombosis can complicate both pulmonary arterial and central venous cannulation by the subclavian route. It occurs much less commonly than internal jugular thrombosis ¹⁵ and is most commonly seen with haemodialysis catheters or when catheter-related sepsis complicates the clinical picture. The incidence is probably reduced by the heparin coating of catheters or systemic heparinisation ¹⁶.

Haemothorax.
Haemothorax (like hydrothorax) is a well-recognised complication of central venous catheterisation by the subclavian approach. The bleeding usually occurs as a result of inadvertent subclavian arterial puncture, but has also been reported as a complication of pulmonary arterial puncture ¹⁷.

Hydrothorax.
Hydrothorax can rarely complicate central venous catheterisation by the subclavian approach ¹⁸, but has apparently not been reported in association with the use of pulmonary arterial catheters. One mechanism whereby it might occur in this context is if the introducer sheath is withdrawn from the vein (with the PAC still in place) and fluids are then administered via the side arm of the sheath.

1. Lefrant JY, Muller L, Nouveoon E et al When subclavian vein cannulation attempts must be stopped? Anesthesiology Supplement 1998. ASCCA abstract B11.

2. Ricolfi F, Valiente E, Bodson F, Poquet E, Chiras J, Gaston A Arteriovenous fistulae complicating central venous catheterization: value of endovascular treatment based on a series of seven cases. Intensive Care Med 1995 Dec;21(12):1043-7

3. Huddy SPJ, McEwan A, Sabbat J. et al: Giant false aneurysm of the subclavian artery. Anaesthesia 44:588-589,1989

4. Kulkarni R; Moreyra AE Left internal mammary artery perforation during Swan-Ganz catheter insertion. Cathet Cardiovasc Diagn, 44:317-9, 1998 Jul

5. Morand P; Masson D; Charbonnier B; Lavigne G; Brehier J Iatrogenic arteriovenous fistula from the internal mammary artery. Arch Mal Coeur Vaiss, 74:105-10, 1981 Jan

6. Sise MJ; Hollingsworth P; Brimm JE; Peters RM; Virgilio RW; Shackford SR Complications of the flow-directed pulmonary artery catheter: A prospective analysis in 219 patients. Crit Care Med, 9(4):315-8 1981 Apr

7. Patel C; Laboy V; Venus B; Mathru M; Wier D Acute complications of pulmonary artery catheter insertion in critically ill patients. Crit Care Med, 14(3):195-7 1986 Mar

8. Plaus WJ Delayed pneumothorax after subclavian vein catheterization. J Parenter Enteral Nutr, 14:414-5, 1990

9. Sivak SL Late appearance of pneumothorax after subclavian venipuncture. Am J Med, 80:323-4, 1986

10. Spiliotis J; Kordossis T; Kalfarentzos F The incidence of delayed pneumothorax as a complication of subclavian vein catheterisation. Br J Clin Pract, 46:171-2, 1992

11. Plewa MC; Ledrick D Delayed tension pneumothorax complicating central venous catheterization and positive pressure ventilation. Am J Emerg Med, 13:532-5, 1995

12. Flanagan JP, Gradisar IA, Gross RJ, Kelly TR. Air embolus - a lethal comlication of subclavian venipuncture. N Engl J Med 1969:281:488-9

13. Ruggiero RP; Caruso G Chylothorax--a complication of subclavian vein catheterization. J Parenter Enteral Nutr, 9:750-3, 1985

14. Khalil KG; Parker FB Jr; Mukherjee N; Webb WR Thoracic duct injury. A complication of jugular vein catheterization. JAMA, 221:908-9, 1972 Aug

15. Timsit JF, Farkas JC, Boyer JM et al Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest, 114:207-13, 1998 Jul

16. Randolph AG, Cook DJ, Gonzales CA, Andrew M Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials. Chest 1998 Jan;113(1):165-71

17. Holt S; Kirkham N; Myerscough E Haemothorax after subclavian vein cannulation. Thorax, 32:101-3, 1977

18. Steiger MJ; Morgan AG Diagnostic aspiration of an iatrogenic hydrothorax following subclavian catheterization. Postgrad Med J, 66(778):672-3 1990

Last edited on: 13/11/2000