BACKGROUND: Central venous access in cancer patients is often challenging. A history of access is common. Appropriate indications for venous imaging studies are not clearly defined. METHODS: This study was a retrospective analysis of selective use of preoperative venous duplex ultrasound and intraoperative venography in 248 consecutive cancer patients undergoing central venous access placement. RESULTS: Ninety patients had a history of central venous access placement. Eleven had a history of deep venous thrombosis of an upper extremity or central vein. One hundred three underwent preoperative ultrasound. Previous central venous access placement was not associated with an abnormal preoperative ultrasound; however, previous central venous access with deep venous thrombosis was (P =.014). Thirty patients underwent intraoperative venography, of which 18 also had preoperative ultrasound. Fifty percent of patients with an abnormal intraoperative venogram had no abnormal findings on preoperative ultrasound. CONCLUSIONS: Routine preoperative ultrasound is unnecessary. We advocate the selective use of preoperative ultrasound in those with a history of central venous access associated with deep venous thrombosis. We advocate the use of intraoperative venography when there is difficulty advancing the guidewire or catheter or when preoperative ultrasound is negative despite a history of central venous access with deep venous thrombosis.