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A D V E R T I S E M E N T
A D V E R T I S E M E N T
Central venous access at the superior thoracic aperture can be safely and efficiently achieved if one understands the anatomy and follows logical principles based on the anatomy. The subclavian and internal jugular veins unite inside the anterior rim of the superior thoracic aperture, forming right and left brachiocephalic veins behind the manubrium. The brachiocephalics unite to form the superior vena cava. The second rib joining the sternal angle marks the mid-point of the vena cava and the third rib marks the caval-right atrial junction. A point between these two landmarks is the ideal position for the catheter tip and is used to approximate catheter insertion length.
A D V E R T I S E M E N T
The heads of the clavicles extend posteriorly into the superior aperture, displacing the veins posteriorly from the sternum. The anterior scalene muscles attach to the first ribs between the subclavian veins and arteries. Because of the AP slope of the superior aperture, the arteries are more cephalad as well as more posterior than the veins. The thoracic duct rises out of the chest, arches over the left subclavian artery and enters the junction of left internal jugular and subclavian veins where it is subject to injury during left sided catheterization. The cupola of the lungs protrude into the aperture behind the vessels. The trachea and esophagus lie centrally.
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A D V E R T I S E M E N T
Both the phrenic nerves and brachial plexus nerves are subject to injury during central catheterization. The phrenic nerves descend from the cervical plexus around the lateral border of the anterior scalene muscles and enter the chest at the medial border of the first ribs just anterior to the insertion of the scalenes where they are vulnerable to injury. The brachial plexus nerves approach and encircle the axillary artery laterally and are relatively protected by their posterior position near the first rib where subclavian puncture is performed.
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This page was last modified on 3/1/1999.
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