Subclavian Central Venous Catheter Placement 
Erin Morris, Ariel Santos and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Subclavian catheters can be temporary or 
permanent, non-tunneled or tunneled, or connected 
to a port under the skin. Tunneling is used only when 
the line is needed long-term, as for dialysis or 
chemotherapy administration. The catheter can be 
single, double or triple lumen depending on the need 
of the patient but taking into account that infection 
rate increase with the number of lumens. The most 
common line used in the critically ill surgical patient 
is a non-tunneled triple lumen catheter, or a “Cordis” 
large bore catheter which allows large volume 
resuscitation.  
Indications for a subclavian central line 
include inadequate peripheral venous access, need 
for large volume resuscitation or advanced 
hemodynamic monitoring, need for central venous 
access for hemodialysis, certain medications, or 
parenteral nutrition, cardiac access for transvenous 
pacing and extracorporeal membrane oxygenation.  
Contraindications for placement of a central 
line include abnormal anatomy and clotted vessel. 
Practice extreme caution in the presence of 
coagulopathy and /or thrombocytopenia. A previous 
clavicle fracture should warrant caution: it may be 
difficult or impossible to safely pass the needle 
beneath the clavicle as described here.  
The subclavian vein is a continuation of the 
axillary vein. At the lateral border of the first rib, the 
axillary vein becomes the subclavian vein where it 
passes over the rib. The axillary artery, which 
becomes the subclavian artery in the same location, 
lies directly posterior to the vein. The subclavian 
vein continues proximally beneath the clavicle 
heading towards the sternal notch until it joins the 
internal 
jugular 
vein 
and 
becomes 
the 
brachiocephalic vein, also called the innominate 
vein. 
 
Veins of the upper extremities, upper chest, and neck. 1. 
Superior vena cava. 2. Vertebral vein. 3. Internal Jugular vein. 
4. External Jugular vein. 5. Subclavian vein. 6. Innominate, or 
Brachiocephalic vein. 7. Brachial vein. 8. Cephalic vein. It is 
possible to achieve central venous access through any of these 
veins; the most commonly used are the Internal Jugular 
(described elsewhere in this Manual,)the Subclavian, and the 
Cephalic (used for “Midline” or Peripherally Inserted Central 
Catheters (PICC.)  
 
Materials:  
● Sterile Drape 
● Local anesthetic  
● 10 mL Saline Flushes  
● 10 mL syringe 
● Retractable scalpel 
● Dilator 
● Guidewire 
● Suture and Needle 
● Central Line Catheter  
● Catheter Caps 
● Dressing 
 
A typical “central line set” will contain most of the items listed 
above. Variably included items include local anesthetic, suture 
and needle, dressing, and saline for flushing the catheter. The 
surgeon is encouraged to make sure these items are present on 
the sterile field before beginning, rather than asking for them 
in the middle of the procedure.  
Subclavian Central Venous Catheter Placement 
Erin Morris, Ariel Santos and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Steps: 
1. Assure that the platelets and coagulation profile 
have been measured recently and are within 
normal limits. Check for a history of previous 
central 
venous 
catheterization 
or 
known 
thrombosis of superficial or deep veins in the 
area.  
2. If available, visualize anatomy using ultrasound. 
This should always be done before and during 
Internal Jugular central line placement, as the 
vein will be cannulated under ultrasound 
guidance (described elsewhere in this Manual.) 
For subclavian access, the ultrasound probe is 
placed parallel to the clavicle at the point where 
the artery and vein pass underneath it.  
 
As shown here, the subclavian veins can be assessed with a 
sterile probe cover on the ultrasound. It is also acceptable to 
assess the veins before preparing and draping the patient, as 
the ultrasound is used for assessment only, not access, in this 
procedure.  
 
3. Prepare your workstation including caps, saline, 
lidocaine, sterile gown and gloves. Flush all the 
ports with sterile saline solution. Proper 
preparation is important here, as your hands will 
be committed during the procedure, and it will be 
difficult to remove caps or connect items 
together. Full body draping and wearing gown, 
mask and gloves have been shown to reduce 
incidence of catheter-related infection.  
4. Prepare the skin widely, including both the 
subclavian and internal jugular access sites on 
both sides, in case the line cannot be placed in the 
originally intended site. Apply sterile drapes.  
5. Inject the skin site with local anesthesia. Try to 
pass the needle under the clavicle and numb this 
area as well, following the same path that you 
will take while inserting the catheter.  
6. Place the patient on reverse Trendelenburg 
position. If the patient is awake, communicate the 
steps of the procedure.  
7. Palpate the clavicle and place one non-dominant 
hand at the top of the clavicle. Place the index 
finger on the sternal notch and the thumb at the 
angle of the clavicle, approximately two-thirds of 
the way lateral from the sternal notch. Utilizing 
the syringe and needle, puncture and advance the 
needle through the skin between the thumb and 
index finger, angling towards the sternal notch 
using the dominant hand.  
 
With the index finger of the non-dominant hand palpating the 
suprasternal notch, pass the needle under the clavicle at the 
place where it angulates in a cranial direction. Avoid lifting 
your hand to “help” the needle pass under the clavicle at an 
angle. Instead, keep the needle horizontal and depress the 
entire needle and syringe towards the floor until the tip passes 
underneath the clavicle.  
 
Subclavian Central Venous Catheter Placement 
Erin Morris, Ariel Santos and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Landmarks for successful subclavian vein access. The clavicle 
has three parts, as shown in this illustration. Find the junction 
between the medial 1/3, which extends transversely, and the 
middle 1/3, which extends obliquely as shown. Puncture the 
skin in a location 2cm lateral and 1cm inferior to this junction. 
Advance the needle under the clavicle, keeping it horizontal, 
and aiming towards your fingertip, a point 1cm above the 
suprasternal notch. 
 
8. Aspirate gently as you advance. Stop once a 
“flash” of dark, non-pulsatile blood is visualized 
in the syringe. If you do not obtain blood, 
withdraw the needle slowly while aspirating: 
sometimes the tip of the needle has punctured 
both walls of the vein simultaneously. As you 
withdraw it, the tip will pass through the lumen 
and you may get a “flash” of blood at this time.  
 
When the tip of the needle is inside the vein, dark red blood will 
suddenly appear in the syringe in a “flash.” Stop inserting or 
withdrawing the needle at this point.  
 
If you are unable to obtain blood initially, remove 
the needle fully from the track before changing 
its direction. The tip of the needle is sharp, it may 
damage surrounding structures and vessel walls 
if it is moved while inside tissue.  
9. Grasp the hub of the needle with your non-
dominant hand and steady it against the chest 
wall. With your dominant hand, gently remove 
the syringe from the needle, making sure that the 
needle does not move at all. Blood should drip in 
a non-pulsatile fashion after the syringe is 
removed from the needle. 
10. Advance the guidewire slowly through the 
needle. There should be no resistance. If 
resistance encountered immediately as the wire 
exits the needle, stop and re-evaluate subclavian 
vein access; most likely your needle tip is no 
longer in the vein. If your guidewire advances for 
20cm or so and then has resistance, it may have 
passed into the contralateral internal jugular or 
subclavian vein. Holding the needle hub steady 
with your non-dominant hand, withdraw the 
guidewire about 15cm and reinsert it. You may 
also try rotating the wire 180 degrees after 
withdrawing it and before reinserting it.  
 
Inserting the guidewire through the needle. The non-dominant 
hand grasps the hub of the needle and steadies itself against the 
patient’s body to avoid any movement. This avoids 
dislodgement of the tip of the catheter from within the vein, or 
damage to the vein by the sharp end of the needle.  
 
11. Once guidewire is in place, slide needle out of the 
patient, holding and maintaining control of the 
guidewire at all times.  
12. Utilize the small retractable scalpel to increase 
the size of the insertion site with the blade facing 
away from the wire.  
Subclavian Central Venous Catheter Placement 
Erin Morris, Ariel Santos and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The scalpel blade is advanced along the guidewire to cut the 
skin as shown below.  
 
The #11 blade is held with the sharp edge facing upwards, and 
the dull edge lying on the guidewire. It is advanced in the 
direction shown by the arrow, cutting the skin just enough to 
allow passage of the dilator(s) and then the catheter itself. 
 
13. Advance the dilator over the guidewire, mild 
resistance is to be expected however the dilator 
should still slide smoothly over the guide wire. 
The guidewire must always move freely within 
the dilator as it advances; if it does not, possibly 
your dilator is following a “false passage” instead 
of the path of the guidewire. Always have full 
control of the guidewire and be holding some part 
of it throughout this process. After you remove 
the dilator, place your gloved finger at the 
insertion site to minimize bleeding. 
If you encounter resistance at the skin, your skin 
incision is not big enough, or not centered over 
the wire. If you encounter resistance below the 
skin, verify that you have not deviated from the 
guidewire’s tract by trying to gently slide the 
guidewire within the dilator.  
 
The guidewire is passed through the tip of the dilator 
 
 
Advance the dilator along the guidewire’s tract, while 
steadying the guidewire itself with the non-dominant hand. The 
guidewire should move freely within the lumen of the dilator as 
it is being advanced, to assure that the dilator does not deviate 
from the tract that the guidewire passes through.  
 
14. Advance the catheter over the guide wire up to 
the desired length which is typically at least 10 
cm. Remove the guidewire. 
Subclavian Central Venous Catheter Placement 
Erin Morris, Ariel Santos and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Advance the catheter over the guidewire along the dilated tract.  
 
15. Aspirate and flush each of the ports with saline to 
confirm patency and ensure removal of any air 
bubbles. Dialysis catheters and implantable port 
catheters should be flushed with heparinized 
saline 1000U per cc, making sure to infuse only 
the volume of the catheter to assure no excess 
heparin enters the patient’s bloodstream.  
 
Each channel is gently aspirated to confirm return of blood, 
then injected with sterile saline. A disposable flush syringe is 
shown here; if you do not have one of these, draw up saline in 
a syringe.  
 
16. Secure the hub of the catheter to the skin using 
suture.  
 
The hub of the catheter is secured to the skin. If this area was 
not injected with local anesthetic, you may need to do so now.  
 
17. Clean the area and cover with sterile dressing. 
 
A sterile dressing; this one was provided by the manufacturer 
of the catheter. Note also the catheter caps, which can easily be 
cleaned, seal each channel of the catheter, and thus reduce the 
risk of infection. 
 
18. Confirm placement with chest x-ray and 
ultrasound if available. The tip of the catheter 
should be at the junction of the superior vena 
cava and the right atrium.  
Subclavian Central Venous Catheter Placement 
Erin Morris, Ariel Santos and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A chest x-ray can confirm that the catheter is inserted to the 
correct depth. An ultrasound cannot confirm the depth of the 
catheter, but it can confirm that it lies within the lumen of the 
vein at its insertion site.  
 
 
Right subclavian catheter in correct position, going downwards 
on the right side of the mediastinum and ending at the junction 
between the superior vena cava and the right atrium. Note that 
in this case the catheter has been tunneled to the medial upper 
right arm, where a port has been placed. Case courtesy of 
Henry Knipe, From the case 
https://radiopaedia.org/cases/29405?lang=us  
 
Pitfalls 
● Cardiac arrythmias: these occur when the wire 
comes into contact with the endocardium of the 
right atrium. Gently pull the wire if arrythmia is 
noted. These arrhythmias, if they occur, also alert 
you that the wire is in the right place, i.e. not in 
the contralateral arm or internal jugular vein. 
They end immediately when the wire is pulled 
back.  
● Arterial 
placement: 
Cannulation 
of 
the 
subclavian artery can be identified via pulsatile 
blood flood through the needle. Worse, 
sometimes pulsatile flow is noted after the tract 
has been dilated and the catheter has been placed. 
If this occurs, gently remove the wire and 
catheter, and apply firm pressure for at least 5 
minutes. Then choose another site for central line 
placement. On chest x-ray, arterial malposition 
of the catheter results in the catheter appearing 
farther to the patient’s 
left within 
the 
mediastinum than would be expected.  
 
 
As shown here, arterial malposition of a central line will cause 
the tip to appear more central in the mediastinum, as it extends 
caudally along the ascending aorta. It may also go downwards 
on the descending aorta, in which case it would be to the 
extreme left of the mediastinum. Case courtesy of Craig 
Hacking, From the case 
https://radiopaedia.org/cases/92311?lang=us  
 
● Venous malposition: The guidewire may go to 
other locations besides the superior vena cava, 
such as the contralateral subclavian vein, or the 
ipsilateral or contralateral internal jugular vein. 
In our experience, when you are not able to pass 
the guidewire to its full length, this complication 
is more likely. Gently try to reposition the 
guidewire through the inserting needle, by 
withdrawing it, rotating it 180 degrees, and then 
re-advancing it. You may need to remove the 
Subclavian Central Venous Catheter Placement 
Erin Morris, Ariel Santos and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
needle completely and reinsert it into the vein at 
a slightly different site or angle.  
● Pulmonary complications: due to proximity to 
the apex of the lung, pneumothorax, hemothorax, 
chylothorax, 
pneumomediastinum, 
recurrent 
laryngeal nerve injury, tracheal injury, and air 
embolism are complications of central line 
placement.  
● Infection: Central line associated blood stream 
infection is common if there is any break in 
asepsis or antiseptic technique during placement 
or improper care of the central line. All central 
lines should be placed with full body drapes and 
gown, gloves, mask and head cover. Remove the 
central line as soon as it is no longer indicated.  
Once an infection has been identified, remove the 
catheter and replace in another site if central line 
is still needed. If possible, remove the catheter 
under sterile conditions and culture the tip to 
identify the organism and know antibiotic 
sensitivities, especially in a critically ill patient.  
● Catheter related venous thrombosis. Having a 
central line in place increases risk of thrombosis 
and thus should be removed if indication for 
placement no longer exist.  
● Device dysfunction: Members of the healthcare 
team should check the catheter for patency daily, 
and if patency is lost, remove and replace in 
another site if necessary.  
 
 
Ariel Santos MD FACS FRCSC FCCM  
Texas Tech University Health Sciences Center  
Lubbock, Texas, USA  
 
Erin Morris MD 
Texas Tech University Health Sciences Center 
Lubbock, Texas, USA  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
June 2023 
