DOI: https://doi.org/10.36347/sjmcr.2026.v14i09.022

Pages: 2048-2051

Ultrasound-guided subclavian vein catheterization significantly improves procedural success and safety; however, intra-luminal dynamic structures such as venous valves can interfere with guidewire advancement. This case series compares two distinct clinical scenarios involving pre-procedurally identified subclavian vein valves during real-time ultrasound-guided infraclavicular catheterization. In Case 1, an 83-year-old female (150 cm, 48 kg) was scheduled for elective brain tumor resection. Pre-procedural longitudinal ultrasound identified a dynamic bicuspid valve leaflet in the right mid-subclavian vein; a precise central in-plane needle trajectory aligned with the longitudinal vessel axis and directed through the center of the valve orifice allowed smooth, unhindered guidewire advancement on the first attempt without resistance. In Case 2, a 31-year-old female (165 cm, 55 kg) presented for emergency posterior lumbar interbody fusion (PLIF) due to an L1 bursting fracture. Real-time longitudinal ultrasound similarly revealed a dynamic venous valve. Initial venipuncture performed distal to the valve yielded free blood return, but firm mechanical resistance was encountered during 0.035-inch J-tip guidewire insertion due to impaction within the valve sinus pocket. Real-time ultrasound confirmed wire buckling. Withdrawing the wire and relocating the puncture site ~ 1.0 cm proximal (cardiac side) to the valve leaflet enabled effortless guidewire passage and successful 7-Fr catheter placement. These cases demonstrate that while the presence of a subclavian vein valve does not universally obstruct guidewire passage, pre-procedural ultrasound mapping, optimal trajectory alignment through the valve orifice, or strategic re-puncture proximal to the valve when resistance occurs are essential steps to ensure safe, complication-free central venous catheterization.