Anaesthesiology

Choice of Vein

There are a number of central veins suitable for cannulation and each has its proponents and critics. The most commonly used sites are:

An important factor in choosing the best site is the operator's own knowledge and experience, as the chance of failure and complications increases if the operator is unfamiliar with the particular technique. For this reason it can be argued that, wherever possible, the technique chosen should be the one the operator is most familiar with.

Several other factors determining the choice of vein are listed below:

Suitability of the vein for the job required
(eg. difficult to pass temporary pacing wires via antecubital veins)
Accessibility of alternative sites
(eg. multiple previous punctures; current infection at puncture site)
Duration of catheter use
(eg. femoral vein not suitable for long term use due to high infection risk in groin)
Success rate
Complication rate
Ease of learning
Urgency of cannulation

A popular choice for central venous cannulation among anaesthetists is the IJV – and not only because this site is often the most accessible introperatively when the rest of the patient is buried under a mountain of sterile drapes! The following table lists some of the pros and cons for each of the common insertion sites.

Central Vein	Pros	Cons
Internal Jugular Vein	Consistent, predictable anatomy Easily palpable landmarks Short straight course to SVC Valveless High success rate (>90%) Carotid artery directly compressable (with care) if punctured	Awkward for patients (lines drag at neck) Accidental pnuemothorax during insertion (mainly with ‘low approach' to IJV) Damage to neck anatomy eg. carotid artery stellate ganglion phrenic nerve
Subclavian Vein	More comfortable for patients than IJV Good for long term cannulation	Higher incidence of pneumothorax than IJV Accidental puncture of subclavian artery during insertion Difficult to apply direct pressure if artery punctured – haemothorax / haemomediastinum possible
Femoral Vein	Low complication rate Femoral artery easy to compress if accidentally punctured	Groin area subject to infection Impairs patient mobility Requires long catheter to reach thorax (eg. for CVP measurement)
External Jugular Vein	Superficial vein – can be cannulated under direct vision Less risk of damage to neck anatomy Rapid cannulation possible	Venous valves may prevent smooth insertion of cannula into central circulation Tortuous course Smaller vessel – large sheaths may tear vessel wall
Antecubital Vein (Basilic and Cephalic)	Low complication rate	High failure rate Increased risk of thrombosis and thrombophlebitis Smaller vessels – large sheaths may tear vessel walls