These are the advices i give to my residents to avoid misplacing cvp's. If you have ultrasound available you could also check the placement of tip before x-ray.

Very correct advice!!! We have studied in detail about this issue of keeping J tip directed downward while advancing it during subclavian puncture, It has then tendency to go towards heart than anywhere else. (Anesthesia Analgesia 2005;100(1): 21-24.)

In my opinion, the most successful method is placing the catheter through posterior approach just above clavicle. In this way the junction of internal jugular to subclavian is accessible as near as possible to surface and perhaps the possibility of misplacement is minimum. I've tried it in more than 15000 patients and found it safe and fruitful.

Accepting your vast experience but for a caution such puncture is likely to damage the jugular venous valve. This in turn might then be associated with IJV flow reversal during atrial contraction. What about the chances of pleural injury in the approach?

Thanks for your comment. In my opinion, we are likely to damage the jugular venous valve in any supraclavicular approach as it is most of the time occurs when we try to force the guide wire against resistance (ie IJ valve). I haven't seen any report of IJV incompetence due to needle damage if we assume that the risk of inserting needle in IJV is higher in posterior approach. With regard to pleural cavity, I have passed the needle into space in a few patients. However, none of them experienced pnemothorax. Besides, we had the chance of checking possible air entrapment in right pleura after sternotomy in most of the cases.