Cephalic vein with a supraclavicular course: rare, but do not forget it exists!
An 82-year-old man underwent the implantation of a dual-chamber pacemaker for symptomatic advanced atrioventricular block. The left cephalic vein was identified in the deltopectoral groove and an hydrophilic guidewire was easily advanced, through a venotomy, into the inferior vena cava. On fluoroscopy, the guidewire showed an anomalous course: it crossed superficially and laterally to the clavicle then turned caudad and entered the subclavian vein in the supraclavicular fossa (Fig. 1). The guidewire could be palpated superficially and anteriorly to the clavicle and in the subcutaneous tissue of the supraclavicular fossa; it was removed and the cephalic vein was tied off. The left subclavian vein was then punctured, pacing leads were advanced through an introducer sheath and positioned in a standard manner (Fig. 2a–b). Cephalic vein cutdown should be the first choice for venous access during device implantation because of the lower risk of complications.1 Cutdown requires some surgical skill and accomodation of multiple leads cannot always be feasible. Stenosis, tortuosity or occlusion can be present but skilful manipulation and the help of an hydrophilic guidewire or introducer sheath can facilitate the passage. Anatomic abnormalities of the vein are possible:2 in 5% of cases it is absent; more rarely (0.2% in autopsy series) after crossing the deltopectoral triangle it ascends anterior and superior to the clavicle to drain into the subclavian or external jugular vein. A supraclavicular course of the cephalic vein has rarely been described during device implantation.3 In these cases, the vein must be abandoned (risk of lead fracture or skin erosion over the clavicle); moreover the guidewire must not be used to guide the puncture of the subclavian vein because of the risk of damage to vital structures in the supraclavicular fossa.