Seldinger puncture of the femoral artery. Catheterization of central veins (subclavian, jugular): technique, indications, complications

Puncture (lat. punclio prick, puncture) is a diagnostic or therapeutic manipulation in which tissue, pathological formation, vessel wall, hollow organ or body cavity are punctured with a needle or trocar. Diagnostic P. allows you to obtain material (tissue...

Scheme of the stages of percutaneous catheterization according to Seldinger: a - puncture of the vessel; b - insertion of the conductor and removal of the needle; c - stringing the catheter; G - ...

News about Scheme of stages of percutaneous catheterization according to Seldinger

If percutaneous coronary intervention (PCI) or bypass surgery is performed simultaneously, the risk of death in the first year after the procedure is higher in women.
However, as reported at the annual scientific session of the American Heart Association by Dr. Lynne Stevenson and colleagues (Brigham and Women's Hospital, Boston, Massachusetts), pulmonary artery catheterization (PAC) does not improve diagnosis or prognosis compared with clinical evaluation alone.

Discussion Scheme of stages of percutaneous catheterization according to Seldinger

Good afternoon Based on the results of the ultrasound, I was shown a puncture. I asked you a question on the forum, you also recommended doing it. I recently had it done by a good specialist, but “blindly”, not under ultrasound control. Result: The isitogram corresponds to chronic autoimmune thyroiditis of the Hashimo type
Before the puncture, I read the reviews and was very afraid, so I decided to write. I had a puncture of the thyroid node, they injected me 2 times, a puncture of the lymph node, and 4 injections. It took 15 minutes, the injections themselves were like not very painful injections. The worst thing is the horror of what they do to you puncture and what they will say. Therefore, if you take

Vein catheterization (central or peripheral) is a procedure that allows for full venous access to the bloodstream in patients requiring long-term or continuous intravenous infusions, as well as for faster emergency care.

Venous catheters are either central or peripheral, accordingly, the former are used for puncturing the central veins (subclavian, jugular or femoral) and can only be installed by a resuscitator-anesthesiologist, and the latter are installed in the lumen of the peripheral (ulnar) vein. The last manipulation can be performed not only by a doctor, but also by a nurse or anesthetist.

Central venous catheter It is a long flexible tube (about 10-15 cm), which is firmly installed in the lumen of a large vein. In this case, special access is provided because the central veins are located quite deep, in contrast to the peripheral saphenous veins.

Peripheral catheter It is represented by a shorter hollow needle with a thin stiletto needle located inside, which punctures the skin and venous wall. Subsequently, the stylet needle is removed, and the thin catheter remains in the lumen of the peripheral vein. Accessing the saphenous vein is usually not difficult, so the procedure can be performed by a nurse.

Advantages and disadvantages of the technique

The undoubted advantage of catheterization is the provision of quick access to the patient’s bloodstream. In addition, when placing a catheter, the need for daily puncture of a vein for the purpose of conducting intravenous drips is eliminated. That is, the patient only needs to install a catheter once instead of having to “prick” the vein again every morning.

Also, the advantages include sufficient activity and mobility of the patient with the catheter, since the patient can move after the infusion, and there are no restrictions on hand movements with the catheter installed.

Disadvantages include the impossibility of long-term presence of the catheter in a peripheral vein (no more than three days), as well as the risk of complications (albeit extremely low).

Indications for placing a catheter in a vein

Often, in emergency conditions, access to the patient’s vascular bed cannot be achieved by other methods due to many reasons (shock, collapse, low blood pressure, collapsed veins, etc.). In this case, to save the life of a seriously ill patient, it is necessary to administer medications so that they immediately enter the bloodstream. And here central venous catheterization comes to the rescue. Thus, the main indication for placing a catheter in the central vein is the provision of emergency and urgent care in an intensive care unit or ward where intensive care is provided to patients with serious illnesses and disorders of vital functions.

Sometimes catheterization of the femoral vein can be performed, for example, if doctors perform (artificial ventilation + chest compressions), and another doctor provides venous access, and does not interfere with his colleagues with manipulations on the chest. Also, catheterization of the femoral vein can be attempted in an ambulance when peripheral veins cannot be found, and the administration of drugs is required in an emergency.

central vein catheterization

In addition, the following indications exist for placing a central venous catheter:

Carrying out open heart surgery using a heart-lung machine (ACB).
Providing access to the bloodstream in critically ill patients in intensive care and intensive care.
Installation of a pacemaker.
Insertion of the probe into the cardiac chambers.
Measurement of central venous pressure (CVP).
Conducting X-ray contrast studies of the cardiovascular system.

Installation of a peripheral catheter is indicated in the following cases:

Early initiation of infusion therapy during emergency medical care. When hospitalized in a hospital, a patient with a catheter already installed continues the treatment that has been started, thereby saving time for placing an IV.
Installation of a catheter in patients who are scheduled for heavy and/or round-the-clock infusions of medications and medical solutions (saline solution, glucose, Ringer's solution).
Intravenous infusions for patients in a surgical hospital, when surgery may be required at any time.
Use of intravenous anesthesia for minor surgical interventions.
Installation of a catheter for women in labor at the beginning of labor so that there are no problems with venous access during childbirth.
The need for repeated sampling of venous blood for research.
Blood transfusions, especially multiple ones.
The patient cannot feed himself orally, and then parenteral nutrition can be administered using a venous catheter.
Intravenous rehydration for dehydration and electrolyte changes in the patient.

Contraindications for venous catheterization

Installation of a central venous catheter is contraindicated if the patient has inflammatory changes in the skin of the subclavian region, in case of bleeding disorders or clavicle injury. Due to the fact that catheterization of the subclavian vein can be carried out both on the right and on the left, the presence of a unilateral process will not prevent the installation of a catheter on the healthy side.

Contraindications for a peripheral venous catheter include the presence of an ulnar vein in the patient, but again, if there is a need for catheterization, manipulation can be performed on the healthy arm.

How is the procedure performed?

No special preparation is required for catheterization of both central and peripheral veins. The only condition when starting to work with a catheter is full compliance with the rules of asepsis and antisepsis, including cleaning the hands of the personnel installing the catheter and thoroughly cleaning the skin in the area where the vein puncture will be performed. Working with a catheter, of course, is necessary with the help of sterile instruments - a catheterization kit.

Central venous catheterization

Catheterization of the subclavian vein

When catheterizing the subclavian vein (with “subclavian”, in the slang of anesthesiologists), the following algorithm is performed:

Video: catheterization of the subclavian vein - training video

Catheterization of the internal jugular vein

catheterization of the internal jugular vein

Catheterization of the internal jugular vein differs slightly in technique:

The patient's position and anesthesia are the same as for catheterization of the subclavian vein,
The doctor, being at the patient’s head, determines the puncture site - a triangle formed by the legs of the sternocleidomastoid muscle, but 0.5-1 cm outward from the sternal edge of the clavicle,
The needle is inserted at an angle of 30-40 degrees towards the navel,
The remaining steps in the manipulation are the same as for catheterization of the subclavian vein.

Femoral vein catheterization

Catheterization of the femoral vein differs significantly from those described above:

The patient is placed on his back with the thigh abducted outward,
Visually measure the distance between the anterior iliac spine and the pubic symphysis (symphysis pubis),
The resulting value is divided by three thirds,
Find the boundary between the inner and middle thirds,
Determine the pulsation of the femoral artery in the inguinal fossa at the obtained point,
The femoral vein is located 1-2 cm closer to the genitals,
Venous access is carried out using a needle and guidewire at an angle of 30-45 degrees towards the navel.

Video: Central venous catheterization - educational film

Peripheral vein catheterization

Of the peripheral veins, the most preferable in terms of puncture are the lateral and medial vein of the forearm, the intermediate ulnar vein, and the vein on the back of the hand.

peripheral vein catheterization

The algorithm for inserting a catheter into a vein in the arm is as follows:

After treating the hands with antiseptic solutions, the required catheter size is selected. Typically, catheters are marked according to size and have different colors - purple for the shortest catheters with a small diameter, and orange for the longest with a large diameter.
A tourniquet is applied to the patient's shoulder above the catheterization site.
The patient is asked to “work” with his fist, squeezing and unclenching his fingers.
After palpation of the vein, the skin is treated with an antiseptic.
A puncture of the skin and vein is performed with a stiletto needle.
The stiletto needle is pulled out of the vein while the catheter cannula is inserted into the vein.
Next, a system for intravenous infusions is connected to the catheter and medicinal solutions are infused.

Video: puncture and catheterization of the ulnar vein

Catheter Care

In order to minimize the risk of complications, the catheter must be properly cared for.

Firstly, the peripheral catheter should be installed for no more than three days. That is, the catheter can remain in the vein for no more than 72 hours. If the patient requires additional infusion of solutions, the first catheter should be removed and a second one should be placed on the other arm or in another vein. Unlike peripheral the central venous catheter can remain in the vein for up to two to three months, but subject to weekly replacement of the catheter with a new one.

Secondly, the plug on the catheter should be flushed with a heparinized solution every 6-8 hours. This is necessary to prevent blood clots in the catheter lumen.

Thirdly, any manipulations with the catheter must be carried out according to the rules of asepsis and antisepsis - personnel must carefully wash their hands and work with gloves, and the catheterization site must be protected with a sterile bandage.

Fourthly, to prevent accidental cutting of the catheter, it is strictly forbidden to use scissors when working with the catheter, for example, to cut the adhesive tape that secures the bandage to the skin.

The listed rules when working with a catheter can significantly reduce the incidence of thromboembolic and infectious complications.

Are complications possible during venous catheterization?

Due to the fact that venous catheterization is an intervention in the human body, it is impossible to predict how the body will react to this intervention. Of course, the vast majority of patients do not experience any complications, but in extremely rare cases this is possible.

Thus, when installing a central catheter, rare complications include damage to neighboring organs - the subclavian, carotid or femoral artery, brachial plexus, perforation (perforation) of the pleural dome with penetration of air into the pleural cavity (pneumothorax), damage to the trachea or esophagus. This type of complication also includes air embolism – penetration of air bubbles from the environment into the bloodstream. Prevention of complications is technically correct central venous catheterization.

When installing both central and peripheral catheters, thromboembolic and infectious complications are serious. In the first case, the development of thrombosis is possible, in the second - systemic inflammation up to (blood poisoning). Prevention of complications is careful monitoring of the catheterization area and timely removal of the catheter at the slightest local or general changes - pain along the catheterized vein, redness and swelling at the puncture site, increased body temperature.

In conclusion, it should be noted that in most cases, catheterization of veins, especially peripheral ones, takes place without leaving a trace for the patient, without any complications. But the therapeutic value of catheterization is difficult to overestimate, because a venous catheter allows for the volume of treatment that is necessary for the patient in each individual case.

The easiest and fastest way to gain access to administer medications is to perform catheterization. Large and central vessels such as the internal superior vena cava or the jugular vein are mainly used. If there is no access to them, then alternative options are found.

Why is it carried out?

The femoral vein is located in the groin area and is one of the large highways that carries out the outflow of blood from the lower extremities of a person.

Catheterization of the femoral vein saves lives, since it is located in an accessible place, and in 95% of cases the manipulations are successful.

Indications for this procedure are:

impossibility of administering drugs into the jugular or superior vena cava;
hemodialysis;
carrying out resuscitation actions;
vascular diagnostics (angiography);
the need for infusions;
cardiac stimulation;
low blood pressure with unstable hemodynamics.

Preparation for the procedure

For femoral vein puncture, the patient is placed on the couch in a supine position and asked to stretch his legs and slightly spread them. Place a rubber cushion or pillow under the lower back. The skin surface is treated with an aseptic solution, hair is shaved off if necessary, and the injection site is limited with sterile material. Before using the needle, locate the vein with your finger and check for pulsation.

The procedure includes:

sterile gloves, bandages, napkins;
pain reliever;
25 gauge catheterization needles, syringes;
needle size 18;
catheter, flexible guidewire, dilator;
scalpel, suture material.

Items for catheterization must be sterile and within the reach of the doctor or nurse.

Technique, Seldinger catheter insertion

Seldinger is a Swedish radiologist who in 1953 developed a method for catheterizing large vessels using a guidewire and a needle. Puncture of the femoral artery using his method is still carried out today:

The space between the symphysis pubis and the anterior iliac spine is conventionally divided into three parts. The femoral artery is located at the junction of the medial and middle third of this area. The vessel should be moved laterally, since the vein runs parallel.
The puncture site is punctured on both sides, giving subcutaneous anesthesia with lidocaine or another anesthetic.
The needle is inserted at an angle of 45 degrees at the site of vein pulsation, in the area of the inguinal ligament.
When dark cherry-colored blood appears, the puncture needle is moved along the vessel 2 mm. If blood does not appear, you must repeat the procedure from the beginning.
The needle is held motionless with the left hand. A flexible conductor is inserted into its cannula and advanced through the cut into the vein. Nothing should interfere with the movement into the vessel; if there is resistance, it is necessary to slightly turn the instrument.
After successful insertion, the needle is removed, pressing the injection site to avoid hematoma.
A dilator is put on the conductor, after first excising the insertion point with a scalpel, and it is inserted into the vessel.
The dilator is removed and the catheter is inserted to a depth of 5 cm.
After successfully replacing the guidewire with a catheter, attach a syringe to it and pull the plunger towards you. If blood flows in, an infusion with an isotonic solution is connected and fixed. Free passage of the drug indicates that the procedure was completed correctly.
After the manipulation, the patient is prescribed bed rest.

Installation of a catheter under ECG control

The use of this method reduces the number of post-manipulation complications and facilitates monitoring of the condition of the procedure., the sequence of which is as follows:

The catheter is cleaned with an isotonic solution using a flexible guide. The needle is inserted through the plug and the tube is filled with NaCl solution.
Lead “V” is attached to the needle cannula or secured with a clamp. The device switches on the “thoracic abduction” mode. Another method suggests connecting the wire of the right hand to the electrode and turning on lead number 2 on the cardiograph.
When the end of the catheter is located in the right ventricle of the heart, the QRS complex on the monitor becomes higher than normal. The complex is reduced by adjusting and pulling the catheter. A tall P wave indicates the location of the device in the atrium. Further direction to a length of 1 cm leads to the alignment of the prong according to the norm and the correct location of the catheter in the vena cava.
After the manipulations are completed, the tube is sutured or secured with a bandage.

Possible complications

When performing catheterization, it is not always possible to avoid complications:

The most common unpleasant consequence is a puncture of the posterior wall of the vein and, as a consequence, the formation of a hematoma. There are times when it is necessary to make an additional incision or puncture with a needle to remove blood that has accumulated between the tissues. The patient is prescribed bed rest, tight bandaging, and a warm compress to the thigh area.
Blood clot formation in the femoral vein has a high risk of complications after the procedure. In this case, the leg is placed on an elevated surface to reduce swelling. Medicines that thin the blood and help resolve blood clots are prescribed.
Post-injection phlebitis is an inflammatory process on the vein wall. The patient's general condition worsens, a temperature of up to 39 degrees appears, the vein looks like a tourniquet, the tissue around it swells and becomes hot. The patient is given antibacterial therapy and treatment with non-steroidal drugs.
Air embolism is the entry of air into a venous vessel through a needle. The outcome of this complication can be sudden death. Symptoms of embolism include weakness, deterioration of general condition, loss of consciousness or convulsions. The patient is transferred to intensive care and connected to a breathing apparatus. With timely assistance, the person’s condition returns to normal.
Infiltration is the introduction of the drug not into a venous vessel, but under the skin. May lead to tissue necrosis and surgical intervention. Symptoms include swelling and redness of the skin. If an infiltrate occurs, it is necessary to make absorbable compresses and remove the needle, stopping the flow of the drug.

Modern medicine does not stand still and is constantly evolving to save as many lives as possible. It is not always possible to provide assistance on time, but with the introduction of new technologies, mortality and complications after complex manipulations are decreasing.

For puncture and catheterization of central veins, the right subclavian vein or internal jugular vein is most often used.

A central venous catheter is a long, flexible tube that is used to catheterize central veins.

The central veins include the superior and inferior vena cava. From the name it is clear that the inferior vena cava collects venous blood from the lower parts of the body, the upper one, respectively, of the head and upper parts. Both veins empty into the right atrium. When placing a central venous catheter, preference is given to the superior vena cava, because the access is closer and the patient’s mobility is maintained.
The right and left subclavian veins, and the right and left internal jugular veins flow into the superior vena cava.

The right and left subclavian, internal jugular veins and superior vena cava are shown in blue.

Indications and contraindications

The following indications for central venous catheterization are distinguished:

Complex operations with possible massive blood loss;
Open heart surgery with AIC and in general on the heart;
The need for intensive care;
Parenteral nutrition;
Possibility of measuring CVP (central venous pressure);
Possibility of taking multiple blood samples for control;
Introduction of a cardiac pacemaker;
X-ray and contrast examination of the heart;
Probing of the cavities of the heart.

Contraindications

Contraindications for central venous catheterization are:

Blood clotting disorder;
Inflammatory at the puncture site;
Clavicle injury;
Bilateral pneumothorax and some others.

However, you need to understand that contraindications are relative, because if a catheter needs to be inserted for health reasons, then this will be done under any circumstances, because To save a person’s life in an emergency, venous access is needed)

For catheterization of central (main) veins, one of the following methods can be selected:

1. Through the peripheral veins of the upper limb, usually the elbow. The advantage in this case is the ease of execution; the catheter is passed to the mouth of the superior vena cava. The disadvantage is that the catheter can remain in place for no more than two to three days.

2. Through the subclavian vein on the right or left.

3. Through the internal jugular vein, also on the right or left.

Complications of central venous catheterization include the occurrence of phlebitis and thrombophlebitis.

For puncture catheterization of the central veins: jugular, subclavian (and, by the way, arteries), the Seldinger method (with a guide) is used, the essence of which is as follows:

1. A vein is punctured with a needle, a conductor is passed through it to a depth of 10 - 12 cm,

3. After this, the guide is removed, the catheter is fixed to the skin with a bandage.

Catheterization of the subclavian vein

Puncture and catheterization of the subclavian vein can be carried out via supra- and subclavian access, on the right or left - it does not matter. The subclavian vein has a diameter of 12-25 mm in an adult, it is fixed by the muscular-ligamentous apparatus between the clavicle and the first rib, and practically does not collapse. The vein has good blood flow, which reduces the risk of thrombosis.

The technique for performing subclavian vein catheterization (subclavian catheterization) involves administering local anesthesia to the patient. The operation is performed under completely sterile conditions. Several access points for subclavian vein cannulation have been described, but I prefer the Abaniak point. It is located on the border of the inner and middle third of the clavicle. The percentage of successful catheterizations reaches 99 -100%.

After treating the surgical field, we cover the surgical field with a sterile diaper, leaving only the surgical site open. The patient lies on the table, the head is turned as far as possible in the opposite direction from the operation, the hand is on the side of the puncture along the body.

Let us consider in detail the stages of subclavian catheterization:

1. Local anesthesia of the skin and subcutaneous tissue in the puncture area.

2. Using a 10 ml syringe from a special set with novocaine and a needle 8-10 cm long, we pierce the skin, constantly injecting novocaine to anesthetize and wash the lumen of the needle, and move the needle forward. At a depth of 2 – 3 – 4 cm, depending on the patient’s constitution and the injection point, there is a sensation of piercing the ligament between the first rib and the collarbone, carefully continue, at the same time pulling the syringe plunger towards you and forward in order to flush the lumen of the needle.

3. Then there is a feeling of piercing the vein wall, while simultaneously pulling the syringe plunger toward yourself, we get dark venous blood.

4. The most dangerous moment is the prevention of air embolism: we ask the patient, if he is conscious, not to breathe deeply, disconnect the syringe, close the needle pavilion with a finger and quickly insert a conductor through the needle, now it is a metal string, (previously just fishing line) similar to a guitar, to the required depth, see 10-12.

5. Remove the needle, move the catheter along the guidewire with rotational movements to the desired depth, and remove the guidewire.

6. Attach a syringe with saline solution, check the free flow of venous blood through the catheter, rinse the catheter, there should be no blood in it.

7. We fix the catheter with a silk suture to the skin, i.e. we stitch the skin, tie knots, then tie knots around the catheter, and for reliability we also tie knots around the catheter pavilion. All with the same thread.

8. Done. We attach the dropper. It is important that the tip of the catheter should not be in the right atrium, there is a risk of arrhythmia. Good and sufficient at the mouth of the superior vena cava.

When catheterizing the subclavian vein, complications are possible; in the hands of an experienced specialist, they are minimal, but let’s consider them:

Puncture of the subclavian artery;
Brachial plexus injury;
Damage to the dome of the pleura with subsequent pneumothorax;
Damage to the trachea, esophagus and thyroid gland;
Air embolism;
On the left there is damage to the thoracic lymphatic duct.

Complications may also be associated with the position of the catheter:

Perforation of the wall of a vein, or of the atrium or ventricle;
Paravasal administration of fluid;
Arrhythmia;
Vein thrombosis;
Thromboembolism.

There is also a possibility of complications caused by infection (suppuration, sepsis)

By the way, with good care, a catheter in a vein can remain for up to two to three months. It is better to change more often, once every one to two weeks, the change is simple: a guide is inserted into the catheter, the catheter is removed and a new one is installed along the guide. The patient can even walk with a drip in his hands.

Catheterization of the internal jugular vein

The indications for catheterization of the internal jugular vein are similar to those for catheterization of the subclavian vein.

The advantage of catheterization of the internal jugular vein is that in this case the risk of damage to the pleura and lungs is much less.

The disadvantage is that the vein is mobile, so puncture is more difficult, since the carotid artery is located nearby.

Technique for puncture and catheterization of the internal jugular vein: the doctor stands at the patient’s head, the needle is inserted into the center of the triangle, which is surrounded by the legs of the sternocleidomastoid muscle (popularly the sternocleidomastoid muscle) and 0.5 - 1 cm laterally, i.e. outward from the sternal end of the clavicle. The direction is caudal i.e. approximately on the tailbone, at an angle of 30-40 degrees to the skin. Local anesthesia is also necessary: a syringe with novocaine, a technique similar to subclavian puncture. The doctor feels two “failures”, a puncture of the cervical fascia and the vein wall. Entering the vein at a depth of 2–4 cm. Further, the same as for catheterization of the subclavian vein.

It’s interesting to know: there is a science of topographic anatomy, and so, the point of confluence of the superior vena cava into the right atrium in the projection onto the surface of the body corresponds to the place of articulation of the second rib on the right with the sternum.

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The Seldinger technique is used to insert the catheter. In this case, the catheter is inserted into the vein along a fishing line - a conductor. Through the needle into the vein (after removing the syringe from the needle and immediately covering its cannula with your finger), a fishing line-conductor is inserted to a depth of approximately 15 cm, after which the needle is removed from the vein. The polyethylene catheter is carried along the guide with rotational and translational movements to a depth of 5–10 cm to the superior vena cava. The guidewire is removed, controlling the location of the catheter in the vein with a syringe. The catheter is washed and filled with heparin solution. The patient is asked to hold his breath for a short time and at this moment the syringe is disconnected from the catheter cannula and closed with a special plug. The catheter is fixed to the skin and an aseptic dressing is applied. To control the position of the end of the catheter and exclude pneumothorax, radiography is performed.

Possible complications.

1. Puncture of the pleura and lung with the development in connection with this of pneumothorax or hemothorax, subcutaneous emphysema, hydrothorax, due to intrapleural infusion.

2. Puncture of the subclavian artery, formation of paravasal hematoma, mediastinal hematoma.

3. During puncture on the left, there is damage to the thoracic lymphatic duct.

4. Damage to elements of the brachial plexus, trachea, and thyroid gland when using long needles and choosing the wrong direction for puncture.

5 Air embolism.

6. A through puncture of the walls of the subclavian vein with an elastic conductor during its insertion can lead to its extravascular location.

Puncture of the subclavian vein.

a - anatomical landmarks of the puncture site, points:

1 (picture below) - Ioffe point; 2 - Aubaniac; 3 - Wilson;

b - direction of the needle.

Rice. 10. Puncture point of the subclavian vein and subclavian direction of needle insertion

Rice. 11. Puncture of the subclavian vein using the subclavian method

Puncture of the subclavian vein using the supraclavicular method from Ioffe's point

Puncture of the subclavian vein.

Catheterization of the subclavian vein according to Seldinger. a - passing the conductor through the needle; b - removing the needle; c - passing the catheter along the guide; d - fixation of the catheter.

1- catheter, 2- needle, 3- “J”-shaped guidewire, 4- dilator, 5- scalpel, 6- syringe – 10 ml

Ticket 77

1. Interscalene space of the neck: boundaries, contents. 2. Subclavian artery and its branches, brachial plexus.

The third intermuscular space is the interscalene gap (spatium interscalenum), the space between the anterior and middle scalene muscles. Here lie the second section of the subclavian artery with the outgoing costocervical trunk and bundles of the brachial plexus.

Inward from the artery lies a vein, posteriorly, above and outward 1 cm from the artery - the bundles of the brachial plexus. The lateral part of the subclavian vein is located anterior and inferior to the subclavian artery. Both of these vessels cross the upper surface of the 1st rib. Behind the subclavian artery there is a dome of the pleura, rising above the sternal end of the clavicle.