Costoclavicular Approach to the Supraclavicular Fossa: Journey behind the Dark Side of the Moon (Clavicle)

I read with interest the report of the use of the costoclavicular space to access the supraclavicular area for a continuous catheter technique,¹  and I commend the authors for their innovative work. It highlights three main questions about supraclavicular catheters: Is there a high catheter displacement rate, is it the most efficacious catheter site, and is the approach described safe?

Displacement rates for perineural catheters range from 5%²  up to 40%.³  A literature search reveals that a small case series of supraclavicular catheters⁴  showed a displacement rate of 10% using the ultrasound-guided lateral to medial approach, which is at the lower end of published rates.

Mariano et al.⁵  found that an infraclavicular catheter provided superior analgesia both in the postanesthesia care unit and during the first 24 h after surgery and allowed for less opioid narcotic compared to a supraclavicular catheter. A small retrospective study found no difference in overall failure rate between infraclavicular and supraclavicular catheters respectively at 24 h.⁶  I would argue that a supraclavicular catheter is not superior to an ultrasound-guided infraclavicular catheter for postoperative analgesia.

Lastly, is the approach described safe? One of the main advantages of ultrasound is the ability to see the needle at all times. This advantage is lost when the needle is blindly advanced behind bone (clavicle). The necessity of keeping the needle out of harm’s way is described here as advancing the needle while “rubbing against the clavicular periosteum, toward the corner pocket” before the needle tip “finally appears as a hyperechoic dot in the ultrasound image” in the supraclavicular fossa. This seems a little like the Apollo space missions where there was loss of radio contact while orbiting the dark side of the moon, and a wait period for contact to resume. As the authors mention, the greatest challenge is to “avoid puncture of the pleura and subclavian vessels,” which are potentially devastating complications. It is my opinion that this approach is not simpler, more efficacious, or safer than existing techniques.

The author declares no competing interests.