A comparison of the supraclavicular approach and the infraclavicular approach for subclavian vein catheterization.

Five hundred emergency department patients requiring subclavian vein catheterization were randomized prospectively into one of two groups, supraclavicular or infraclavicular. If catheterization was unsuccessful in a few attempts using the randomized approach, catheterization with the alternate approach was attempted. Two catheters were available for use, a short, 8-French introducer and a long, 16-gauge catheter. There were 38 failures (15.5%) among 245 patients in the supraclavicular group, with one malposition and five complications. There were 51 failures (20.0%) among 255 patients in the infraclavicular group, with 21 malpositions and 13 complications. No differences were significant except that of malpositions (P less than .01). The combination of infraclavicular approach and 16-gauge catheter accounted for 21 of 22 malpositions. When catheterization by the randomized approach failed, catheterization by the alternate approach was successful in all but seven cases, resulting in an overall success rate of 98.6%. Analysis of this series suggests that both the infraclavicular and supraclavicular approaches to subclavian vein catheterization are acceptable alternatives, with little difference in success rate or complications. Using an alternate approach if the initial approach was unsuccessful produced a high overall success rate and a low overall complication rate. A physician who is familiar with both approaches will be more successful at placing central venous catheters safely.