To the Editor, Further to the article titled ‘‘Ultrasound-Guided Radiological Placement of Central Venous Port via the Subclavian Vein: A Retrospective Analysis of 500 Cases at a Single Institute’’ by Sakamoto et al. [1], we would like to congratulate the authors and make the following comments. In their paper recently published in Cardiovascular and Interventional Radiology [1], the authors reported the results of the largest retrospective study regarding real-time ultrasound (US)-guided insertion of chest port devices by interventional radiologists. Contraindications to chest port insertion for local causes represented approximately 1% of cases. This rate is similar to our experience, which is devoted to treatment of head, neck, and breast cancer patients. In the authors’ study, the population consisted of almost 64% of gastrointestinal malignancies; the male-to-female sex ratio was 1.2; and left-sided venous access was performed in 89% of cases. To further improve the technique, we suggest free-hand venous puncture performed with the patient in the Trendelenburg position, which always promotes filling of the patient’s subclavian (SVC) and jugular veins. In this case, free-hand technique puncture can be performed without using syringe suction. In our opinion, the Valsalva maneuver does not significantly increase the diameter of the SCV, whose anatomical location is far more constant than that of the jugular vein [2]. Its diameter is less; varies during cardiac respiratory cycles; and seems to be more affected by the patient’s volemia [3]. In fact, according to our own experience we even noticed complete SCV collapse during inspiration on preoperative US scanning. Noteworthy, in Sakamoto’s study, 42% (3 of 7 patients) of the SCV access– failure cases presented with a permanently collapsed SCV and probably would have benefited from intravenous ipsilateral arm fluid rehydration. Furthermore, patients C50 years old frequently have tortuous aortic arch collaterals and subsequent risk of catheter misplacement due to venous mediastinal loops. The latter are better managed by a skilled interventional radiologist who is familiar with catheterization ‘‘tips and tricks,’’ i.e., the use of a hydrophilic guidewire and gentle back-and-forth motion/rotation of the introducer sheath and catheter. Contralateral rotation of the patient’s neck and full inspiration are useful tools when the catheter abuts, and stops, at the vena cava wall. We also stress that left-sided catheterization appears far easier in such cases: The venous route is longer, with a less sharp angle than on the right side, and thus guidewire manipulations are easier. This probably explains the reason why almost 90% of the study patients’ venous accesses were performed on this side [1]. We also advocate pushing the guidewire far down into the inferior vena cava to straighten P. Y. Marcy (&) A. Ianessi Interventional Radiology Department, Antoine Lacassagne Cancer Research Institute, Sophia Antipolis University, 06189 Nice Cedex 1, France e-mail: pierre-yves.marcy@cal.nice.fnclcc.fr; pymarcy@hotmail.com