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©2013 UpToDate ® Print Email Advantages and disadvantages of central vein approaches Approach Advantages Disadvantages External jugular Superficial vessel that is often visible Coagulopathy not prohibitive Minimal risk of pneumothorax (especially with US guidance) Head-of-table access Prominent in elderly patients Rapid venous access Not ideal for prolonged venous access Poor landmarks in obese patients High rate of malposition Catheter may be difficult to thread Internal jugular Minimal risk of pneumothorax (especially with US guidance) Head-of-table access Procedure-related bleeding amenable to direct pressure Lower failure rate with novice operator Excellent target using US guidance Not ideal for prolonged access Risk of carotid artery puncture Uncomfortable Dressings and catheter difficult to maintain Thoracic duct injury possible on left Poor landmarks in obese/edematous patients Potential access and maintenance issues with concomitant tracheostomy Vein prone to collapse with hypovolemia Difficult access during emergencies when airway control being established Subclavian Easier to maintain dressings More comfortable for patient Better landmarks in obese patients Accessible when airway control is being established Increased risk of pneumothorax Procedure-related bleeding less amenable to direct pressure Decreased success rate with inexperience Longer path from skin to vessel Catheter malposition more common (especially right SCV) Interference with chest compressions Femoral Rapid access with high success rate Does not interfere with CPR Does not interfere with intubation No risk of pneumothorax Trendelenburg position not necessary during insertion Delayed circulation of drugs during CPR Prevents patient mobilization Difficult to keep site sterile Difficult for PA catheter insertion Increased risk of iliofemoral thrombosis US: ultrasound; SCV: subclavian vein; CPR: cardiopulmonary resuscitation; PA: pulmonary artery. With permission from: Factor P, Sznajder JI. Vascular cannulation. In: Principles of Critical Care, Hall JB, Schmidt GA, Wood LDH (Eds), McGraw-Hill, New York, 1992. Copyright 1992 McGraw-Hill.