We thank Dr. Han for his comments on our article, ''Brachiocephalic Veins: An Overlooked Approach for Central Venous Catheterization'' (Badran et al., 2002), which was based on the findings of Mina (1959). At the end of our article we concluded that ''Although we realize that clinical practice can reveal differences or aspects not encountered in experiments on cadavers, on the basis of our present findings we recommend the introduction of this technique into clinical practice.'' Following its publication, at least three papers have been published on catheterization of the brachiocephalic vein.
The first paper was by Schummer et al. (2003), who successfully performed a Doppler-guided cannulation of the brachiocephalic vein along with the internal jugular and subclavian veins. They stated that although the brachiocephalic venous lines have not become popular cannulation sites, they are suitable vessels for Doppler-guided cannulation, with 96 and 100% success rate in the first and second attempts, respectively.
The second paper by Abigail ( 2006) used Doppler ultrasound guidance on 33 patients undergoing hemodialysis. The procedure was extremely successful.
The third paper was by Massad et al. (2008). They investigated the brachiocephalic approach in central venous catheterization guided by Doppler ultrasound in 26 patients undergoing cardiac surgery. The procedure was successful in 92.3% of cases. They concluded that, using Doppler ultrasound guidance, the brachiocephalic vein is a suitable site for central venous catheter insertion in cardiac surgery.
Gray's Anatomy (Standring, 2005) described the relations of the internal thoracic artery as follows ''At first the internal thoracic artery descends anteromedially behind the sternal end of the clavicle, the internal jugular and brachiocephalic veins and the first costal cartilage.'' Regarding the right brachiocephalic vein, Standring (2005) indicates that ''the right pleura, phrenic nerve, and internal thoracic artery are posterior to it above, becoming lateral below.'' The left brachiocephalic vein ''crosses anterior to the left internal thoracic, subclavian and common carotid arteries, left phrenic and vagus nerves, trachea and brachiocephalic artery.'' During cannulation of the brachiocephalic veins, the creation of negative pressure in the syringe will fill the syringe with blood indicating that the needle is in the correct position and that no further advancement of the needle is required. This will prevent the needle penetrating the vessel wall and injuring nearby structures. The ligaments of the joint will prevent displacement of the catheter and will help in directing it toward the vein.
Finally, radiological techniques (e.g., CT, ultrasound) will assist in the proper placement of the catheter and reduce complications in any approach used, and maintain the brachiocephalic approach as an option.