Anterior Chest Wall

A. Insertion of a central venous catheter (Figure 3-2A). Access to the superior vena cava (SVC) and the right side of the heart is required to monitor blood pressure, maintain long-term parenteral feeding, or administer drugs. The internal jugular vein (IJV) and subclavian vein (SCV) usually are used.

1. IJV (central or anterior approach). The needle is inserted at the apex of a triangle formed by two heads of the sternocleidomastoid muscle and the clavicle on the right side.

2. SCV (infraclavicular approach). The index finger is placed at the sternal notch, and the thumb is placed at the intersection of the clavicle and first rib as anatomic landmarks. The needle is inserted below the clavicle and lateral to the thumb on the right side.

3. Complications of a central venous catheter include: puncture of the subclavian artery or SCV, pneumothorax, hemothorax, trauma to the trunks of the brachial plexus, arrhythmia, venous thrombosis, erosion of the catheter through the SVC, damage tu the tricuspid valve, and infection.

B. Postductal coarctation of the aorta (see Figure 3-2B)

1. Postductal coarctation of the aorta is a congenital malformation that may be associated with increased blood pressure to the upper extremities, diminished and delayed femoral artery pulse, and increased risk of cerebral hemorrhage and bacterial endocarditis.

2. Postductal coarctation of the aorta usually is located distal to the left subclavian artery and the ligamentum arteriosum.

3. Collateral circulation involves the internal thoracic artery > intercostal arteries ► superior epigastric artery > inferior epigastric artery external iliac arteries. These arteries bypass the constriction and become dilated. Dilation of the intercostal arteries causes erosion of the lower border of the ribs, or rib notching.

4. Preductal coarctation is less common. It occurs proximal to the ductus arteriosus. When preductal coarctation occurs, blood reaches the lower part of the body through a patent ductus arteriosus.

C. Aneurysm of the aorta. Aneurysm of the aorta may compress and tug on the trachea with each cardiac systole so that the aneurysm can be felt by palpating the trachea at the sternal notch (T2).

Lower trunk of brachial

Anterior Chest Wall MusclesPreductal Circulation

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