CVC Site Selection

Internal Jugular Vein

  • Right internal jugular vein is the preferred site of CVC placement for novice operators, but always assess both left and right sides to compare vein size and depth. If the bilateral jugular veins are small and/or deep, check to see if the femoral veins are a more favorable target.
    • Pro Tip: The “best” location for a CVC is the site where you are most likely to be successful. Use your ultrasound to select large and superficial veins when possible.

  • Right IJ preferred over left IJ since it is a straighter course into the SVC and usually bigger than the left internal jugular vein, and the right side may be associated with a reduced rate of complications.
  • Jugular vein is normally lateral or superficial to the artery.
  • Insert the needle at least 2-3 finger breadths above the clavicle
    • Pro Tip: US often reveals that the internal jugular vein is largest at the clavicle, but starting the skin puncture too close to the clavicle often results in the needle tip entering the thoracic cavity, causing pneumothorax, hemothorax, and subclavian artery cannulation.
  • As seen below, the junction of the 2 heads of the sternocleidomastoid is the most common location of skin puncture, but always evaluate with ultrasound as well2

Femoral Vein

  • Stay below the inguinal ligament to ensure your puncture site is in the thigh, and not in the retroperitoneum. Vascular injury above the inguinal ligament is not compressible and can lead to massive retroperitoneal bleeding.
    • Pro Tip: The crease at the top of the thigh/groin is below the inguinal ligament and is often the best site for skin puncture because the femoral vein is larger and more superficial. Below the crease, the vein starts to dive deep and hide below the artery.
  • Femoral vein is located approximately 1 cm medial to femoral artery

Subclavian Vein

  • Subclavian placement has been shown to have lowest rates of VTE and CLABSI, but highest rates of life threatening mechanical complications.
  • This should only be attempted by experienced providers

Next Page: Preparing for the Procedure

References

  1. Parienti JJ, et al. “Intravascular Complications of Central Venous Catheterization by Insertion Site”.The New England Journal of Medicine. 2015. 373(13):1220-1229.
  2. Bannon MP, Heller SF, Rivera M. Anatomic considerations for central venous cannulation.Risk Management and Healthcare Policy. 2011;4:27-39. doi:10.2147/RMHP.S10383.