The Supraclavicular Subclavian


    The Supraclavicular Subclavian

    Traditionally, central line placement in the subclavian vein (SCV) involves a landmark-based approach in which the needle is guided under the clavicle. For the U/S lovers, there is an alternative approach to the subclavian in which the sono may be utilized: the supraclavicular subclavian.

    Anatomy: The goal is to cannulate the SCV just lateral to clavicular head of the sternocleidomastoid muscle. The right SCV is preferred as it forms a straighter angle with internal jugular, and thus a shorter path to the superior vena cava. Furthermore, the thoracic duct, a structure you would prefer not to damage, drains into the the left SCV. You aim just lateral to where the ext jugular vein joins the SCV.

    Technique: As always, perform standard sterile and needle precautions to minimize harm to yourself and to the patient. With the linear probe, start by visualizing the internal jugular and following it inferiorly until your ultrasound abuts the clavicle. You should see the confluence of the IJV and SCV forming the brachiocelphic vein. You may angle posteriorly to visualize the pulsating subclavian artery to confirm your position (figure 1a). Then angle anteriorly to identify where the external jugular enters the SCV for the ideal location for cannulation (see figure 1b). Reposition, and then enter the skin slowly and follow your needle tip with the in-plane technique (this should be easier than most standard in-plane tracting of the needle as your needle and U/S probe are pushed against the clavicle. From there you may use your standard confirmation of adequate placement techniques (eg, manometry, aspiration, visualization of the guide wire in the SCV). Get the post-placement x-ray to r/o ptx and confirm placement.


    1. Visualization of the anatomy may be a challenge in the pts with a large BMI or short neck.
    2. The technique relies on use of the in-plane guidance of the needle in the subclavian, a technique that we are less familiar with. It seems like PTX risk may be less given the use of U/S, but keep in mind that your are pointing your needle down towards the lung (unlike the infraclavicular approach) and if you lose sight of your needle tip, then you can easily drop a lung.


    Consider the supraclavicular subclavian when your go to IJ isn’t an option (abnormal neck anatomy, IJV thrombosis, presence of a c-collar).

    Thank you Ryan for lending me your beautiful veins!!!


    1. Mallin M, Louis H, Madsen T. A novel technique for ultrasound-guided supraclavicular subclavian cannulation. Am J Emerg Med. 2010;28:966-969.
    2. Leiu, C, et al. Using the Supraclavicular Approach to Ultrasound-Guided Subclavian Vein Cannulation. ACEP Now. Available at: Accessed Aug 2018.
    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Put down that FOBT

      “The HgB has dropped, have you checked a guaic?” How many times have you checked a FOBT in your workup for anemia? Let’s take a look at what FOBT is supposed to be used for. FOBTRead more

    • A ‘normal’ chest Xray

      What do you see when you take a look at this Chest radiograph? It isn’t immediately noticeable (and was read as normal), and is a good reminder of why you should always check your ownRead more

    • Overshot that INR

      There have been a few cases of supra-therapeutic INR in the Sinai ED recently, and at the request of one of our superstar interns, below you will find a brief set of recommendations regarding SupratherapeuticRead more

    • Ketamine PSA with Desaturation

      During a busy day in the ED, it becomes apparent that the pulling and yanking on your patient’s shoulder has done absolutely nothing to reduce their shoulder. You perform your pre-procedure PSA Checklist, know that thisRead more

    • Sinusitis In Pediatrics?

      You’re working in pediatrics, when a mother comes in stating her 5 year old has sinusitis. He presents with fever, cough, runny nose, and some discomfort over where his frontal sinuses are. Does he haveRead more

    • Ring Removal

      Over the past week, we’ve had a strange uptick in number of patients presenting to the ER with rings stuck on their finger. This is a quick review on the options that you have regardingRead more

    • TPA For Minor Stroke?

        So, you’re working in the ED when a new stroke code is activated. You walk over and see a young gentleman with the complaint of left facial tingling, right arm and leg weakness withRead more

    • Central Line Wizardry

      I was scrolling through twitter this morning when I came across a quick video from @CriticalCareNow for an awesome central line trick. And then I went to his feed and found some more. They areRead more