Right internal jugular vein:
Right internal jugular venepuncture offers the most direct approach to the heart with little risk of pneumothorax. Against this must be weighed the facts that the consequences of accidental carotid puncture (particularly in the elderly or coagulopathic patient) may be disastrous and that the site itself is difficult to dress and, as a consequence, may be associated with a higher incidence of catheter-related sepsis.

Left internal jugular vein:
The left internal jugular is a more difficult approach for right-handed anaesthetists than the right, offers a less direct route to the heart and appears to be associated with a high incidence of cannulation of persistent left superior vena cava (if present) ^{1, 2}.

Subclavian vein:
Subclavian venepuncture (Figure 1) carries practically no risk of carotid puncture and the consequences of accidental subclavian arterial puncture are usually not severe. In addition, although the route to the heart is apparently less direct than for the right internal jugular approach, the natural curve of catheter more accurately reflects the curvature of the venous path from subclavian vein to right ventricle and pulmonary artery (Figure 2). However, pneumothorax remains a significant risk of the approach and, if the left side is used, there is a small risk of thoracic duct injury.

The left innominate vein is occasionally intentionally divided (and subsequently reconstituted) during aortic arch surgery - which may preclude the use of the left subclavian or jugular approaches.

External jugular vein:
The external jugular vein is occasionally chosen as the route for insertion, but in our experience has a low rate of successful entry into the central circulation. Two early reports suggested that access could be achieved in over 90% of cases when the Seldinger technique was used ^{3, 4}, however the technique has not gained widespread acceptance. The effect of manipulation of the shoulder (in order to facilitate passage of the J-wire past the clavicle) during external jugular vein catheterization has been examined prospectively by Sparks et al ⁷. In a group of 111 patients, the wire could not be passed into the thorax on 25 occasions. In 10 of these cases manipulation of the shoulder then allowed the wire to pass.

Peripheral venous cannulation:
A more peripheral approach by the cephalic or basilic vein is generally associated with a lower incidence of major complication, but is also much less likely to result in rapid entry into the pulmonary circulation unless image intensification is available. The use of a 'blind' approach to the central circulation using the cephalic or basilic vein carries a successful placement rate of about 75% ⁵. This rate may be improved slightly by turning the head towards the side of insertion of the catheter at the time of passage so as to reduce the likelihood of entry into the ipsilateral jugular vein. These peripheral approaches to the central circulation have the advantage that they entail practically no risk of air embolism.

Special, stiffer catheters are available for use via the femoral vein and a series with a 95% successful placement rate using this route without the benefit of fluoroscopic control has recently been published ⁶.

Whichever route is selected, a pulmonary artery catheter introducer sheath must be placed in the chosen vein through which the catheter is inserted. Placement of the introducer sheath (Figure 3) is best achieved using the Seldinger ⁷ technique (Video 2).

1. Lai YC, Goh JCY, Lim SH et al Difficult Pulmonary Artery Catheterization in a Patient with Persistent Left Superior Vena Cava. Anaesth Intensive Care 1998; 26: 671-673

2. Sweitzer BJ; Hoffman WJ; Allyn JW; Daggett WJ Diagnosis of a left-sided superior vena cava during placement of a pulmonary artery catheter. J Clin Anesth, 5:500-4, 1993

3. Blitt CD, Wright WA, Petty WC et al: Cardiovascular catheterization via the external jugular vein. A technique employing the 'J' wire. JAMA 229:817-818, 1974

4. Youngberg JA Pulmonary artery catheterization via the external jugular vein. South Med J, 75(3):289-90 1982

5. de Lange SS, Boscoe MJ, Stanley TH Percutaneous pulmonary artery catheterization via the arm before anaesthesia: success rate, frequency of complications and arterial pressure and heart rate responses. Br J Anaesth 1981 Nov;53(11):1167-72

6. Findling R, Lipper Femoral vein pulmonary artery catheterization in the intensive care unit. Chest 1994 Mar;105(3):874-7

7. Sparks CJ, McSkimming I, George L Shoulder manipulation to facilitate central vein catheterization from the external jugular vein. Anaesth Intensive Care 1991 Nov;19(4):567-8

Last edited on: 26/11/2000