In some cases, the axillary vein may be difficult to access because located too deep or collapsed during the inspiratory act. Also. its diameter may be unsuitable for the size of catheter that the patient needs. In such cases, we recommend to adopt a supra-clavicular access, i.e. ultrasound-guided puncture and cannulation of the internal jugular vein (visualization in short axis, 'in plane' puncture) or of the brachio-cephalic subclavian or external jugular vein (for all three: long axis view, 'in plane' puncture).
The brachio-cephalic vein is probably the easiest and safest vein to cannulate under ultrasound guidance: it is a large caliber, it does not collapse with the respiratory acts, and it does not carry the risk of accidental puncture of the pleura or arterial structures.
The internal jugular vein should preferably be visualized in a short axis (or oblique axis) and punctured 'in plane'. The 'out of plane' puncture of the internal jugular in short axis is not recommended: it is less easy, it is associated with the risk of accidental arterial puncture, and moreover it implies an unfavorable emergency site (at mid-neck).
The ultrasound-guided puncture of the subclavian vein is almost always exclusively by a supra-clavicular approach. It is less easy and less safe than the puncture of the brachio-cephalic vein.
The last tract of the external jugular vein (before the confluence in the subclavian) is not always identifiable on ultrasound in the adult, but can sometimes be seen as a long vein that is posterior, superior and parallel to the subclavian vein.
All four approaches described above imply a supra-clavicular exit site. In particular cases, it may be indicated to tunnel the catheter to obtain an exit site in the infra-clavicular area.