Ultrasound-guided infraclavicular axillary vein access for central venous catheterization: an evidence-informed narrative review

This evidence-informed narrative review addresses a longstanding anatomical inconsistency between the axillary vein (AXV) and subclavian vein (SCV), whereby some studies labeled as ultrasound-guided ’subclavian' catheterization actually puncture the AXV lateral to the first rib. We integrate first-rib-based anatomy, preprocedural ultrasound assessment, puncture strategy, device selection, guidewire and catheter-tip management, comparative outcomes, complications, training, and implementation across the complete infraclavicular AXV access pathway. PubMed/MEDLINE, Embase, and Web of Science Core Collection were searched from inception through August 6, 2026, supplemented by guideline searches and citation tracking. Direct randomized evidence and a recent meta-analysis suggest that, in selected patients and trained operators, short-term overall catheterization success and early mechanical outcomes are broadly similar to internal jugular access, although the available evidence does not independently establish formal equivalence. Proximal targeting and arm-position optimization may improve procedural efficiency in selected settings, but effects vary with respiratory state, anatomical definition, side, and operator technique. Current evidence does not establish a long-term infection or thrombosis advantage or a universally superior ultrasound imaging plane. Guidewire and catheter malposition after successful venipuncture further show that puncture success alone is an incomplete safety endpoint. Infraclavicular AXV access should therefore be considered one of several potential first-line options in appropriately selected patients and trained teams, not a universal replacement for other central venous routes. We propose an externally unvalidated implementation framework linking nomenclature, dynamic target selection, needle-tip control, guidewire navigation, tip confirmation, immediate complication exclusion, securement, and maintenance.