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Interact CardioVasc Thorac Surg 2009;9:343-344. doi:10.1510/icvts.2009.205328
© 2009 European Association of Cardio-Thoracic Surgery
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Brief communication - Cardiac general

Superior vena cava clamping for brachiocephalic vein cannulation during heart surgery

Erkan Kuralay*

Department of Cardiovascular Surgery, UFUK University, Yazanlar Sokak 31/11, Asagi Ayranci, Ankara 06540, Turkey

Received 15 February 2009; received in revised form 10 March 2009; accepted 11 March 2009

*Corresponding author. Tel.: +90 312 468 1773/GSM: +90 533 230 9656; fax: +90 312 285 5767.

E-mail address: erkanece2000{at}yahoo.com (E. Kuralay).


   Abstract
Top
 Abstract
1. Introduction
 2. Surgical technique
 3. Discussion
 References
 
A new central venous catheterization during open heart surgery is seldom required. Clamping of superior vena cava (SVC) causes adequate brachiocephalic vein distension which facilitates vein puncture. In our experience, ~20 s is enough for adequate brachiocephalic vein distension. I usually prefer subclavian vein puncture by supraclavicular approach. By this approach, average superior vein clamping time is about 45 s.

Key Words: Superior vena cava clamping; Central vein cannulation; Venipuncture


   1. Introduction
Top
 Abstract
 1. Introduction
2. Surgical technique
 3. Discussion
 References
 
A new central venous catheterization during open heart surgery is seldom required. The major causes of this requirement are removal of the previous central venous line accidentally, pinch-off phenomenon or additional line requirement for rapid fluid replacement. Insertion of a new central line in a draped patient during the operation without disturbing sterilization is not easy. Reverse Trendelenburg position is mostly used for promoting distension of brachiocephalic veins which facilitates vein cannulation. Herein, we describe a new technique for central venous cannulation during open heart surgery.


   2. Surgical technique
Top
 Abstract
 1. Introduction
 2. Surgical technique
3. Discussion
 References
 
Left or right supraclavicular area is prepared in patients whose jugular vein was cannulated previously during open heart surgery. Puncture needle and guide wire are also prepared. Superior vena cava (SVC) is clamped and vein puncture is done after 20 s (Fig. 1). In our experience, ~20 s is enough for adequate brachiocephalic vein distension. I have observed an increase of about two-fold after clamping in the diameter of brachiocephalic truncus and upper part of SVC. At the beginning, we performed digital compression instead of clamping but adequate SVC and brachiocephalic distension was not obtained. Although slight variations in technique of subclavian vein cannulation by supraclavicular approach may exist, the most common and simplest technique is to puncture the skin 1 cm cephalad and medial to the midpoint of clavicle. In most individuals, the described point for skin puncture is ~1 cm lateral to the lateral border of sternocleidomastoid muscle (SCM) and is quite close to the originally described point, ‘exactly at’ or ‘just behind’ the angle of the SCM and the clavicle. The needle course should bisect the angle of the SCM and the clavicle, and is directed 10–20° anterior to the coronal plane to avoid injury to the artery or pleura. The vein is encountered quite superficially, typically at 0.5–1.5 cm depth, with a characteristic appearance as the needle enters the lumen [1–4]. Guide-wire is placed through the needle after puncture of central vein and then SVC clamp is released. Average time period of SVC clamping is 45 s. Then vein cannulation is done. Supraclavicular approach is routinely used for subclavian vein cannulation in my department.


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  		Fig. 1. Left supraclavicular area is prepared in patients whose jugulary vein was cannulated previously during open heart surgery. Cannulation needle and guide wire are also prepared. Superior vena cava is clamped and vein puncture is done after 20 s. ~20 s is enough for adequate brachiocephalic vein distension.

 

   3. Discussion
Top
 Abstract
 1. Introduction
 2. Surgical technique
 3. Discussion
References
 
Inadvertently removal of a central vein line is rarely experienced by the cardiac operation team. Pinch-off phenomenon may also develop in patients due to placing of a retractor after sternotomy. Rarely, a new central venous line may be required for inotropic administration or rapid fluid replacement. Reinsertion of a central line in alternative anatomic localizations is much more difficult during open heart surgery. Femoral veins may not be used due to inadequate draping or increased risk of infection. Brachiocephalic vein cannulation requires distension of subclavian veins. Surgeons use reverse Trendelenburg position for brachiocephalic vein distension. Hemodynamic derangement may develop during the reverse Trendelenburg position. I have clamped SVC for brachiocephalic vein distension which facilitates vein puncture. On average, 45 s clamping period is enough for a successful brachiocephalic vein cannulation. I have not experienced any hemodynamic derangement during the SVC clamping period. I usually prefer supraclavicular approach for subclavian vein cannulation which is simple and easy during open heart surgery. In addition, left jugular vein may be also used after SVC clamping. Of course, some learning curve is necessary to obtain adequate experience. Recently, I have punctured subclavian vein by supraclavicular approach in the first attempt while the heart surgery is being carried out.


   References
Top
 Abstract
 1. Introduction
 2. Surgical technique
 3. Discussion
 References
 

  1. Sterner S, Plummer DW, Clinton J, Ruiz E. A comparison of the supraclavicular approach and the infraclavicular approach for subclavian vein catheterization. Ann Emerg Med 1986;15:421–424.[CrossRef][Medline]
  2. Brahos GJ. Central venous catheterization via the supraclavicular approach. J Trauma 1977;17:872–877.[Medline]
  3. Haapaniemi L, Slatis P. Supraclavicular catheterization of the superior vena cava. Acta Anaesthesiol Scand 1974;18:12–22.[Medline]
  4. Muhm M, Sunder-Plassmann G, Apsner R, Kritzinger M, Hiesmayr M, Druml W. Supraclavicular approach to the subclavian/innominate vein for large-bore central venous catheters. Am J Kidney Dis 1997;30:802–808.[CrossRef][Medline]

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eComment: Superior caval vein clamping
Sedat Ziyade, Elvin Tanriverdi, Oguzhan Karatepe, and Barbaros Kinoglu
Interactive CardioVascular and Thoracic Surgery 2009 9: 344. [Full Text] [PDF]



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S. Ziyade, E. Tanriverdi, O. Karatepe, and B. Kinoglu
eComment: Superior caval vein clamping
Interactive CardioVascular and Thoracic Surgery, August 1, 2009; 9(2): 344 - 344.
[Full Text] [PDF]

This Article
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Erkan Kuralay
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