INTENSIVE CARE

Central venous
cannulation: ultrasound
techniques

Learning objectives
After reading this article, you should be able to:
C
list the indications for central venous cannulation and describe
the commonly used insertion sites
C
explain the advantages of ultrasound-guided CVC insertion
C
describe the limitations of the technique and potential pitfalls
for the novice operator
C
understand the importance of needle-tip visualization and
avoidance of arterial cannulation

Simon Flood
Andrew Bodenham

Abstract
Central venous cannulation is commonly undertaken by a range of
specialities in diverse clinical settings. Central veins may be cannulated by the landmark, ultrasound-guided or open surgical cut-down
techniques. Complications of central venous catheter (CVC) insertion
are common and may lead to signicant morbidity and very occasional
mortality. Two-dimensional ultrasound-guided central venous catheter
placement has been shown by randomized controlled trials to be superior to the landmark technique. It reduces both the number of needle
passes required for successful placement and the incidence of complications. Constant needle-tip visualization is a challenge for the novice
operator. The UK National Institute for Health and Care Excellence
(NICE) has recommended since 2002 that following appropriate
training, clinicians should use ultrasound wherever practical in both
elective and emergency internal jugular vein catheterization. Most clinicians would now recommend its use for all routes of access.

entering the vein in real time. Indirect guidance describes using

ultrasound to confirm the position of a patent vein prior to
cannulation. Although less demanding for the novice, it does not
provide all the advantages of direct techniques. Central veins
may also be cannulated by a surgical cut down.

Complications of CVC insertion

Complications from attempted CVC insertion are common.
Depending on case mix and operator skill, up to 10% of attempted
cannulations lead to a complication. Complication rates correlate
to the number of needle passes and may lead to significant
morbidity and occasional mortality.2 Common complications
include arterial puncture, haematoma and pneumothorax.

Keywords Central venous catheter; femoral; jugular; subclavian

veins; ultrasound; venous cannulation

Ultrasound technology
Two-dimensional ultrasound uses high-frequency sound, reflected
from tissue interfaces, to generate an image of superficial structures. Fluid-filled structures such as blood vessels appear dark.
Air, bone and needles are hyperechogenic and appear bright.
Structures deep to air or bone will not be visualized (acoustic
shadowing). Low-frequency sound penetrates deeper than high
frequency, but produces lower-resolution images. Central veins
are generally accessed within a few centimetres of the skin, so
high-frequency (7.5e10 MHz), high-resolution probes are used.
Two-dimensional ultrasound may be combined with Doppler
imaging (Duplex) to show blood flow and direction. This can be
useful in differentiating arteries from veins (Table 1).

Royal College of Anaesthetists CPD Matrix: 2A04

Indications for central venous access

Central venous catheters (CVCs) are commonly inserted to
facilitate monitoring (i.e. central venous pressure, cardiac
output) or delivery of drugs (e.g. vasopressors, chemotherapy
agents) into the central circulation. CVCs also allow provision of
total parenteral nutrition, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), venovenous bypass
(VVBP) in liver transplantation or transvenous cardiac pacing.

Distinguishing features of arteries and veins under

ultrasound

Methods of cannulation
The traditional landmark technique relies on using surface
anatomical features and palpable arterial pulses as a guide to
deeper structures. Ultrasound guidance may be direct or indirect.1 Direct guidance uses ultrasound to visualize the needle

Simon Flood MRCP FRCA DICM is a Consultant in Anaesthesia and

Intensive Care Medicine at The Leeds Teaching Hospitals NHS Trust,
UK. Conict of interest: none declared.
Andrew Bodenham FRCA FFICM is a Consultant in Anaesthesia and
Intensive Care Medicine at The Leeds Teaching Hospitals NHS Trust,
UK. Conict of interest: AB has received honoraria from ultrasound
manufacturers for teaching courses.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

Arteries

Veins

Pulsatile

Non-pulsatile

Not easily compressed,

visualization improves with
compression

Easily compressed

Round

Elliptical

Characteristic pulsatile
Doppler signal

Characteristic more continuous

Doppler signal change shape on
respiration/valsalva

Table 1

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INTENSIVE CARE

Limitations of the technique

All new clinical skills have an associated learning curve and
ultrasound-guided cannulation does not easily grant novices
immediate success. Adequate training, practice and supervision
are required to gain competence. An appreciation of how 2D
images relate to 3D anatomy is essential. Constant visualization
of needle-tip position may initially be difficult to maintain and
loss of the needle-tip view risks complications.

Insertion sites
The internal jugular vein (Figure 2) is a superficial structure lying
adjacent to the carotid artery. It is often the most convenient site
of access in the anaesthetized patient. There is wide variability in
the relationship (including overlap) between artery and vein and
some patients will have a dominant venous circulation on one
side of the neck.
The subclavian vein is preferred in the head-injured patient
(minimal effect on intracranial pressure) or for prolonged access.
The clavicle restricts visualization of the subclavian vein, but by
moving a short distance laterally, the axillary artery and vein
may be visualized (Figure 3). Further laterally, the operator will
note a greater distance between vein and pleura, reducing the
risk of pneumothorax. This advantage is balanced by a smaller
diameter and deeper vessel compared with a more medial
approach. It may be difficult to visualize and access the vein in
obese or muscular patients. Supraclavicular approaches are also
used.
The femoral vein is favoured in those unable to tolerate headdown positioning. Traditional teaching suggests the superficial
femoral artery does not cross the femoral vein until several
centimetres below the inguinal ligament. Radiological studies
have shown crossover is higher than commonly appreciated.3
Ultrasound allows verification of anatomy and accurate first
pass puncture of the common femoral vein.
High-frequency ultrasound can identify peripheral veins in the
limbs. This is useful in the obese or intravenous drug user and
may facilitate central venous access with a peripherally inserted

Figure 1 Non-compressible thrombus completely blocking the right

subclavian vein. More commonly there will be a crescent of thrombus
partially blocking the vein. White arrow, chest wall/pleura; SCA, subclavian artery.

Advantages of ultrasound
Ultrasound can identify aberrant anatomy or thrombosed/stenosed vessels (Figure 1). In both scenarios, alternative access
sites should be sought and useless needle passes avoided.
Ultrasound can detect valves or collapsed veins. Valves are
avoided by adjusting the needle insertion point. Empty veins are
more easily cannulated following fluid resuscitation, head-down
positioning, IPPV/PEEP or Valsalva manoeuvre. Ultrasound may
identify guidewire or catheter misplacement, for example imaging the neck during subclavian vein cannulation may identify
retrograde passage into the internal jugular vein. Arteries
accompanying the major veins are easily visualized with ultrasound. In well-filled veins, real-time ultrasound allows the
operator to cease forward movement of the needle once the
anterior wall is penetrated and the needle-tip lies within the
lumen, avoiding posterior vein wall puncture and haematoma
formation. Vessel transfixion may be unavoidable when cannulating an empty vein. The pleura lies immediately posterior to the
subclavian vessels and is easily visualized by ultrasound
(Figure 1); it is also at risk from a low internal jugular approach.

Figure 2 Cross-sectional view of right internal jugular vein (IJV) and carotid artery (CA) with needle introduced in the short axis. (a) Needle tip is
seen just indenting the anterior vein wall. (b) Needle further indents the vein wall but the tip is still covered by vein wall which is tented into the
lumen, no blood can be aspirated. (c) Needle tip has passed through the vein wall to lie within lumen, vein has re-expanded and correct position is
conrmed by free aspiration of blood. The green dot in the upper right-hand corner of each image is an orientation marker. The probe is correctly
orientated when a palpable marker on the probe is on the same side as the green dot on display. This ensures that right and left in the image
correspond correctly to medial and lateral on the patient.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

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INTENSIVE CARE

Needle-tip visualization
The spatial relationship between needle and probe may be short
or long axis and the image cross-sectional or longitudinal. It is
common to use a cross-sectional view and short axis insertion
(Figure 2). This method provides excellent visualization of surrounding structures. It takes practice to maintain constant
needle-tip visualization as the tip may inadvertently pass through
the beam and the shaft be mistaken for the tip. Alternatively, the
vein may be imaged longitudinally and the needle inserted in the
long axis. This gives superior needle/wire views but does not
provide concurrent images of surrounding structures (Figure 4).
Some needles have their distal 1 cm machined to make them
more echogenic. Many operators now suggest using crosssectional vessel visualization and needle in plane approaches
or hybrid variations of techniques.
Figure 3 Cross-sectional view of axillary vein (AV) and artery (AA).
Note: the small circular arterial branch anterior to the vein (arrow).

Verication of needle/wire/catheter placement

Inadvertent arterial puncture by a needle or guidewire is usually
remedied without serious sequelae by careful removal and
application of sustained direct pressure. Dilatation over a wire or
cannulation of an artery can be associated with severe morbidity
(cerebrovascular accident, local haemotoma, haemothorax, A-V
fistula) and occasional mortality.5,6 The American Association of
Anaesthetists (ASA) recommends a four stage position verification procedure.7 Arterial puncture cannot be ruled out by colour
of aspirated blood or the absence of pulsatile flow. Needle-tip
position should therefore be confirmed primarily by real-time
ultrasound, with secondary checks if required by blood gas
analysis or pressure monitoring. Secondly, central guidewire
position can be confirmed by ultrasound, or transoesophageal
echocardiography. Thirdly, before use, venous placement of the
catheter itself should be confirmed by ultrasound, pressure
monitoring or fluoroscopy. Aspiration of blood does not exclude
malposition of the catheter.6,8 Finally, the catheter tip position
should be checked on a chest radiograph. The tip should be sited
in as large a vein as possible, ideally outside the heart/pericardium and parallel with the long axis of the vein.9 Particular care
should be taken with left internal jugular or left subclavian lines
that the tip does not abut the lateral wall of the superior vena
cava.
In the event of inadvertent arterial dilatation/cannulation, the
device should be left in situ and the urgent advice of an interventional radiologist or vascular surgeon sought. The dilator/
catheter may then be safely removed under fluoroscopic guidance or at open surgery with measures in place to manage subsequent haemorrhage, embolus or dissection.7
A

central catheter (PICC) in the mid upper arm to avoid flexure at

the elbow.

Evidence for ultrasound guidance

A Cochrane review examining internal jugular vein cannulation
concluded ultrasound reduced the rate of total complications, the
incidence of inadvertent arterial puncture and the number of
attempts required before successful cannulation compared with
the landmark technique.4 Ultrasound also reduced the time to
successful cannulation.

Equipment preparation
The display should be positioned on the opposite side of the
patient to the operator. The image should anatomically be in the
orientation as seen from the position of the operator. An orientation marker in the image (as shown by a green dot used by the
manufacturers of the devices used in Figures 2 and 3) should be
matched to a palpable marker on the probe. Correct orientation
ensures that the image moves in a logical direction when the
probe is moved and that the needle moves in the same direction
in the patient as on the display. If in doubt, touch the scan surface at one end of the probe and watch for the accompanying
display artefact.

REFERENCES
1 Lamperti M, Bodenham AR, Pittiruti M, et al. International evidencebased recommendations on ultrasound-guided vascular access.
Intensive Care Med 2012; 38: 1105e17.
2 Manseld PF, Hohn DC, Fornage BD. Complications and failures of
subclavian-vein catheterisation. N Engl J Med 1994; 331: 1735e8.
3 Hughes P, Scott C, Bodenham A. Ultrasonography of the femoral
veins, implications for vascular access. Anaesthesia 2000; 55:
1199e202.

Figure 4 A J-tipped guidewire passing through a needle entering a

mock vein, imaged longitudinally, in an agar phantom. T, tip.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

2015 Elsevier Ltd. All rights reserved.

INTENSIVE CARE

4 Brass P, Hellmich M, Kolodziej L, et al. Ultrasound guidance versus

anatomical landmarks for internal jugular vein catheterization.
Cochrane Database Syst Rev 2015; 1: CD006962.
5 Booth SA, Norton B, Mulvey DA. Central venous catherterization
and fatal cardiac tamponade. Br J Anaesth 2001; 87: 298e302.
6 Jankovic A, Boon A, Prasad R. Fatal haemothorax following largebore percutaneous cannulation before liver transplantation. Br J
Anaesth 2005; 95: 472e6.
7 American Society of Anesthesiologists TaskForce on Central
Venous Access. Practice guidelines for central venous access.
Anesthesiology 2012; 116: 539e73.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

8 Hohlrieder M, Schubert H, Biebl M, Kolbitsch C, Moser P, Lorenz L.

Successful aspiration of blood does not exclude malposition of a large
bore central venous catheter. Can J Anaesth 2004; 51: 89e90.
9 Fletcher A, Bodenham A. Safe placement of central venous catheters: where should the tip of the catherter lie? Br J Anaesth 2000;
85: 188e91.
FURTHER READING
ld F, et al. Clinical guidelines on
Frykholm P, Pikwer A, Hammarskjo
central venous catheterisation e a review article. Acta Anaesthesiol
Scand 2014; 58: 508e24.

2015 Elsevier Ltd. All rights reserved.