Comparison between supraclavicular and infraclavicular approaches for ultrasound-guided right subclavian venous catheterization in major elective surgeries and ICU patients
Authors: Mahmoud Wael A. , Ahmed Islam M. , Hamed Maha A. , Sallam Wesam A. 
Published: December 2023

Background
Central venous catheterization is an important device that is frequently performed for various purposes in operating theatres and intensive care units, there are many different sites that are commonly used for central venous catheterization, and each site has its own advantages, disadvantages, and possible complications. To avoid catheterization failure and mechanical complications, ultrasound guidance is currently recommended in several guidelines and is widely used for central venous catheterization. It has been shown to reduce the incidence of arterial puncture, hematoma formation, pneumothorax, hemothorax, and catheterization failure. The subclavian vein (SCV) catheterization is more comfortable for patients than other sites but has a higher risk of some complication as pneumothorax. The aim of this study was to compare the Supraclavicular and Infraclavicular approaches for ultrasonographic guided right subclavian venous catheterization as regard the accessibility and the safety of both approaches.

Methods
This randomized controlled study was conducted in Sohag University Hospital after local ethical committee approval, 210 patients had a right subclavian vein catheterization by either the supraclavicular or the infraclavicular approach (105 for each group), using a two dimensional high-frequency ultrasound guide were enrolled in the study regarding the accessibility (time to first puncture and number of punctures) and the complications like arterial puncture, hematoma formation, arrhythmia, and catheter misplacement.

Results
The infraclavicular approach is more accessible, regarding the number of punctures, for the Supraclavicular approach there were 56 (53.3%) cases needed only one puncture to achieve successful venous puncture and 27 (25.7%) cases needed 2 punctures and 5 (4.8%) needed 3 punctures and 17 (16.2%) failed in catheterization, for the Infraclavicular approach there were 79 (75.2%) of cases in these group needed only one puncture to achieve successful venous puncture and 17 (16.2%) cases needed 2 punctures and 9 (8.6%) failed in catheterization with a significant difference between both groups P value was 0.003. As regard the puncture time, for the Supraclavicular approach 83 (79%) cases successes in less than 3 min, and 22 (21%) cases needed more than 3 min, in the infraclavicular approach 94 (89.5%) cases succeeded in less than 3 min and 11 (10.5%) cases needed more than 3 min at P value 0.037 and had a lower rate of complications than the supraclavicular approach, like arrhythmia, arterial puncture, hematoma formation, catheter misplacement, and postcatheterization infection, but a higher rate of pneumothorax formation however in a nonsignificant way.

Conclusion
The infraclavicular approach for ultrasound-guided right subclavian venous catheterization is better than the supraclavicular approach due to a higher chance of first pass success rate and a lower rate of complications.