By cannulating a vein in the supra-clavicular area (internal jugular, brachio-cephalic, subclavian), the exit site naturally falls in the supraclavicular fossa (care should be taken to orient the catheter laterally, and not upward towards the neck).
In some cases, however, it is necessary that the exit site is in the subclavicular area (a very favorable site in terms of controlling the risk of infection, thrombosis and dislocation); the catheter can then be tunneled downwards, below the clavicle. This occurs for example in the presence of a tracheostomy, where it is advisable to move the exit site caudally to at least 7-8 cm far from the ostomy, to minimize bacterial contamination via the extraluminal route.
Tunneling is also very appropriate in infants and very young children, where the management of the exit site in the supraclavicular area is always problematic.
We recommend the off-label use of catheters marketed as PICCs, which have the advantage of considerable length (50 cm and more) and insertion with modified Seldinger technique (which simplifies the tunneling maneuver). The catheter will be placed in the best available central vein (the one whose puncture appears easier, and therefore safer) after an ultrasound evaluation of the region (RaCeVA), following a standardized implant protocol, such as the SICA-Ped protocol (Safe Insertion of Central Access in Pediatric patients) developed by GAVeCeLT.