Demonstrating the anatomical relationship of the scalene muscle, subclavian/brachial artery and vein, and the relation of the clavicle regarding these two vessels.
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Topography of the subclavian vein
![Topography of the subclavian vein]()
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Infiltrating the surgical site with local anesthetic
![Infiltrating the surgical site with local anesthetic]()
Insert needle about 1 finger width inferior to the clavicle at roughly its middle and apply a total of 10 mL of local anesthetic, both as a wheal and in subclavian direction.
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Puncturing the subclavian vein
![Puncturing the subclavian vein]()
Puncture the vein with the needle initially at 70°-90° to the clavicle; after feeling no more resistance and with the needle definitely inferior to the clavicle, change the direction and advance the needle toward the (marked) suprasternal notch. Verify correct intraluminal placement by drawing venous blood into syringe.
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Seldinger technique
![Seldinger technique]()
Once intravenous access has been gained, insert the guidewire through the needle. Make a stab incision with a scalpel (no. 11) and then insert the dilator with the introducer.
Remove the guidewire and cover the introducer with a fingertip to prevent any air embolism (here not always illustrated adequately).
Remove the dilator while keeping the introducer in place.
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Inserting the port tubing
![Inserting the port tubing]()
Insert the port tubing step by step while simultaneously pulling back the introducer and swinging down the sheath.
Optional: Fluoroscopy + administration of contrast agent to verify the location of the port tubing within the superior vena cava.
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Preparing the port pouch
![Preparing the port pouch]()
Incise skin along the cleavage line about 4 cm distal to the puncture site and create a subcutaneous pouch with enough space for about 2 fingertips.
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Subcutaneous tunneling
![Subcutaneous tunneling]()
Now create subcutaneous tunnel with appropriate dilating forceps and pull tubing through.
Verify tubing location by fluoroscopy and shorten tubing to correct length.
Attach tubing to port outlet using the mosquito clamp (with its branches sheathed in plastic tubing).
The distal end of the tubing must be slipped completely over the nipple and secured there by the cuff clicking into place.
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Final functional verification
![Final functional verification]()
Before suturing the skin, gain transcutaneous access to the port chamber and possibly re-image the catheter system by contrast-enhanced fluoroscopy.
A postoperative chest film will help rule out puncture-induced pneumothorax and verify the correct position of the TIVAD.
