ORIGINAL COMMUNICATION Defining the Surface Anatomy of the Central Venous System in Children GREGORY P. TARR, 1 NEDA PAK, 2 KIARASH TAGHAVI, 3 TOM IWAN, 4 CHARLOTTE DUMBLE, 4 DAVID DAVIES-PAYNE, 1 AND S. ALI MIRJALILI 4 * 1 Department of Radiology, Auckland City Hospital, Auckland, New Zealand 2 Department of Radiology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran 3 Department of Paediatric Surgery, Wellington Hospital, Wellington, New Zealand 4 Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand Pediatric emergency physicians, pediatric critical care specialists, and pediatric surgeons perform central venous catheterization in many clinical settings. Complications of the procedure are not uncommon and can be fatal. Despite the frequency of application, the evidence-base describing the surface landmarks involved is missing. The aim of the current study was to critically investigate the surface markings of the central venous system in children. The superior vena cava/right atrial (SVC/RA) junction, superior vena cava (SVC) formation, and brachiocephalic vein (BCV) formation were examined independently by two investigators. Three hundred computed tomography (CT) scans collected across multiple centers were categorized by age group into: 0–3 years, 4–7 years, and 8–11 years. Scans with pathology that distorted or obscured the regional anatomy were excluded. The BCV formation was commonly found behind the ipsilateral medial clavicular head throughout childhood. This contrasts with the variable levels of SVC formation, SVC length, and SVC/RA junction. In the youngest group, SVC formation was most commonly at the second costal cartilage (CC), but moved to the first CC/first intercostal space (ICS) as the child grew. The SVC/RA junction was at the fourth CC in the youngest group and moved to the third CC/third ICS as the child grew. This study demonstrates the variable anatomy of SVC formation and the SVC/RA junction with respect to rib level. This variability underscores the unreliability of surface anatomical land- marks of the SVC/RA junction as a guide to catheter tip position. Clin. Anat. 29:157–164, 2016. V C 2015 Wiley Periodicals, Inc. Key words: central venous catheterization; vascular access devices; superior vena cava; brachiocephalic vein; right atrium INTRODUCTION Central venous catheterization was first introduced in the 1950s by Aubaniac, who stated “elle est stricte- ment sans danger (it is strictly without danger)” (Aubaniac, 1952). This bold claim of uniform safety has subsequently been disproven in multiple publica- tions, but central venous catheterization nonetheless remains a core component of: pediatric emergency and critical care, pediatric oncology, and the treat- ment of chronic pediatric diseases (e.g., cystic fibro- sis, coagulopathies, and renal failure). *Correspondence to: S. Ali Mirjalili, Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, Univer- sity of Auckland, Auckland, New Zealand. E-mail: a.mirjalili@auckland.ac.nz Disclosure: The authors have no conflict of interest. Received 14 October 2015; Revised 20 October 2015; Accepted 28 October 2015 Published online 23 November 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ca.22663 V V C 2015 Wiley Periodicals, Inc. Clinical Anatomy 29:157–164 (2016)