When cannulating a vein in the supra-clavicular area (internal jugular, brachio-cephalic, subclavian), the emergency site naturally falls into the supra-clavicular fossa (as the extravascular tract of the catheter is placed laterally and not towards the neck).
In some cases, however, if the clinical situation asks for an exit site in the infra-clavicular area (a very favorable location in terms of controlling the risk of infection, thrombosis and dislocation), the catheter can then be tunneled downward. This occurs for example in the presence of a tracheostomy, where it is advisable to move the exit site caudally to at leas 7-8 cm far from the ostomy, to minimize bacterial contamination via the extraluminal route.
As a type of catheter, since tunneling is necessary, it will be useful to use catheters commonly marketed as PICCs, particularly suitable for tunneling both for their length (around 50 cm) and for the insertion technique (modified Seldinger). The catheter will be placed in the best available central vein (the one whose puncture appears easiest and therefore safest) after an ultrasound assessment of the region (RaCeVA - Rapid Central Vein Assessment), following a standardized implant protocol, such as the SICA protocol (Safe Insertion of Central Access) developed by GAVeCeLT.