Appraisal of the dislocation of central venous catheter tips using subclavian and arm veins.

The most dramatic of the complications resulting from central venous catheterization is perforation of the heart. We studied the complications reported in the literature and undertook an original investigation of the dislocations of peripherally and infraclavicularly inserted catheters while moving the arm and shoulder in patients during autopsy. In a postmortem examination of three patients it was found that the greatest displacement, up to eight centimetres, of the tips of the catheters occurred when they were inserted through the basilic vein. The tips of infraclavicular inserted catheters did not move at all during movements of the arm. Only by extreme movements of the shoulder we were able to show a maximal displacement of two centimetres. Advancement of the catheter tip occurred during adduction and flexion of the elbow joint and not during abduction. Our experimental evidence suggests that the best site for a catheter tip is the upper part of the right atrium. We therefore recommend the subclavian route for in-dwelling central venous catheters rather than insertion through an arm vein, as this minimizes the risk of cardiac perforation due to its great stability.