The patient is placed in a 15° Trendelenburg position to increase central venous pressure and thereby reduce the chances of air embolism. The subclavian vein has greater exposure if the shoulders are hyperextended over a rolled towel placed longitudinally between the scapula under the thoracic spine. The head should be turned to the opposite side. Under these conditions, the subclavian vein becomes more accessible. The skin over the neck and upper thorax is prepped in a routine fashion. Aseptic technique should be followed. A 2-inch, 14-gauge needle attached to a 10-mL syringe with 2-3 mL of heparinized saline solution in the syringe should be inserted through the skin with the bevel of the needle pointing down. The ideal site for the puncture is at the inferior border of the middle of the clavicle directed toward a fingertip pressed firmly into the suprasternal notch. The needle should be passed beneath the inferior margin of the clavicle in a horizontal plane and directed toward the anterior margin of the trachea at the level of the suprasternal notch. The needle and syringe are kept parallel to the surface of the patient's bed and adjacent to the anterior wall of the subclavian vein in the direction of its long axis. The accuracy of the placement into the subclavian vein can be demonstrated by a copious flow of blood into the barrel of the syringe with slight negative pressure. The syringe is removed from the hub of the needle, and the thumb is immediately placed over the hub.

A flexible guidewire is inserted through the hub of the needle and passes into the superior vena cava (SVC).

When the guidewire is securely in the superior vena cava, the needle is withdrawn over the guidewire and removed.

The guidewire is shown as it enters the skin under the clavicle. The ideal site for the Port-A-Cath chamber is selected; it is between two ribs, approximately 8cm from the point where the guidewire enters the skin. A 4-cm incision is made in this area, and a pocket is created under the subcutaneous fat on top of the pectoralis fascia. Hemostasis in this pocket is essential.

The subcutaneous pocket is demonstrated by placing the Port-A-Cath, with the catheter attached, into the pocket. At this point, the eyes on the Port-A-Cath flange are sutured to the fascia of the pectoralis muscle with 3-0 nylon sutures.

The Port-A-Cath and the catheter are filled with heparinized saline solution. This is achieved by inserting a Huber needle attached to a syringe of heparinized saline. The entire Port-A-Cath and catheter are filled with saline solution before any attempt is made to insert the catheter into the venous system.

A 1-cm incision is made adjacent to the guidewire underneath the clavicle. An alligator-mouth grasping forceps is tunneled through the small incision down to the larger subcutaneous pocket. The alligator-mouth jaws grasp the catheter and pull it through the subcutaneous pocket, out through the incision next to the guidewire in the subclavian vein.

The Port-A-Cath chamber is shown at the lower right. The skin incision over the Port-A-Cath is closed with fine suture or the skin stapler. At this point, a vein dilator sheath is inserted over the guidewire through the 1-cm skin incision under the clavicle and down into the subclavian vein. Note that the catheter exits the skin adjacent to the vein dilator sheath.

The guidewire is withdrawn through the vein dilator sheath and removed. A finger is inserted over the vein dilator to prevent air from entering the subclavian vein. The Port-A-Cath catheter is measured from the subcutaneous pocket up to the subclavian vein and down an estimated distance in the superior vena cava. The excess catheter is cut away with sharp scissors.

The catheter is threaded through the vein dilator sheath into the subclavian vein and, ultimately, into the superior vena cava.

The vein dilator sheath is constructed so that it will tear away as it is pulled out of the subclavian vein. This is achieved by placing the finger on each flange of the vein dilator sheath. An assistant threads the catheter farther into the superior vena cava. The sheath is withdrawn as it is split apart. The vein dilator sheath is removed entirely.

At this time an x-ray picture is taken (either by fluoroscopy or from the flat plate of the chest) to ascertain the position of the catheter. If it is in the right atrium, it is withdrawn 4-5 cm through the skin incision. When the catheter is in the appropriate position, the skin incision is closed with fine suture or skin staples. A heparinized saline solution in a 10-mL syringe with a Huber needle is placed through the skin into the Silastic diaphragm Port-A-Cath, and the entire system is flushed with 10mL of heparinized saline solution.