Medial venous puncture

It is important to maintain the patient in the anatomic position. Maneuvers that artificially open the costoclavicular and infraclavicular spaces should be avoided. The common practices of placing towels between the scapulae or extending the arm may result in undesirable puncture of the costoclavicular ligament or subclavius mnscle. The medial venous puncture clearly increases the success rate as well as dramatically reduces the risk of pneumothorax and vascular injury. 

Fig. 4.19 Deep (A) and superficial (B) anatomic relationships of the Magney approach to subclavian vena puncture. Point M indicates the medial end of the clavicle. X defines a point on the clavicle directly above the lateral edges of the clavicular/subclavius muscle (tendon complex). Rl. Point D overlies the center of the subclavian vein as it crosses the first rib. St, the center of the sternal angle Cp, coracoid process Ax, axillary vein star, costoclavicular ligament open circle with closed circle, costoclavicular ligament open circle with closed circle inside, costoclavicular ligament sm, subclavius muscle. The arrow points to Magney s ideal point for venous entry. (Magney JE, Staplin DH, Flynn DM, et al. A new approach to percutaneous subclavian venipuncture to avoid lead fracture or central venous catheter occlusion. Pacing Clin Electrophysiol 1993 16(11) 2133-2142, with permission.)...

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